Get Oh Odm 09401 2019-2026

The Ohio Department of Medicaid Form ODM 09401 is essential for reporting admissions, discharges, and deaths in nursing facilities. This guide provides clear, step-by-step instructions to help you accurately fill out this form online.

Follow the steps to complete the OH ODM 09401 form online.

1. Click ‘Get Form’ button to obtain the OH ODM 09401 and open it in the online editing interface.
2. Begin with Section I: Resident Information. Fill in all required fields, including the first name, last name, Medicaid number, social security number, middle initial, date of birth, and if applicable, the Medicaid application date. Ensure that the information is accurate.
3. Proceed to Section II: Facility Information – Admission. Indicate the admission date and select the type of admission. Provide additional details if applicable, such as the plan name and any comments.
4. Next, fill out Section III: Facility Information – Discharge or Death. Enter the discharge date and reason for discharge. If the reason is death, specify the date of death.
5. In Section IV: Submitter Information, input the submitter's name, facility name, Medicaid provider number, email address, telephone number, and the date of submission.
6. After completing all sections, review the information for accuracy. Once confirmed, follow the instructions for submission using the secure portal.
7. Finally, save changes, download, print, or share the completed form as necessary.

Complete your OH ODM 09401 form online today to ensure timely reporting.