Get Oh Odm 10193 2016-2025

Filling out the OH ODM 10193 form is an important step in managing your Medicaid benefits through a qualified income trust. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the OH ODM 10193 form online.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. In the individual information section, enter the name of the individual in the format of last name, first name, and middle initial. Provide the date of birth in mm/dd/yyyy format. Fill in the 12-digit Medicaid ID number and the case number. Include the individual's street address, apartment or unit number, city, and zip code.
3. Proceed to the trust information section. Enter the name of the trustee in the same format as the individual name. Specify the county and provide the date the trust was established in mm/dd/yyyy format.
4. Input the name of the location where the trust account was established, along with the street address, city, building or unit number, state, and zip code.
5. Next, fill in the account name and account number. Include the contact name for the account and their phone number for further inquiries.
6. Indicate the source of income by checking all applicable options such as Social Security, company retirement, veteran benefits, railroad retirement, or other sources. Provide the necessary amounts and specify the source where applicable.
7. Record the amount to be deposited into the trust and the effective date of the deposit in mm/dd/yyyy format. Also, include the monthly account maintenance fee.
8. Have the trustee sign and date the form in the designated areas to confirm all information provided is accurate.
9. Once complete, you can save your changes, download the form, print it, or share it as needed.

Take the next step in managing your Medicaid benefits by completing the OH ODM 10193 form online today.