Follow the steps to successfully fill out the OH ODM 02374 form.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the consumer information section. Include the first name, middle initial, and last name of the individual requesting services. Enter their 12-digit Medicaid number, phone number(s), and if applicable, the name and phone number(s) of the authorized representative.
3. Indicate the effective date requested for private duty nursing services. Make sure this is accurate, as it affects the timing of service initiation.
4. Select the waiver type applicable to your request. Choose between the ODA-administered waiver (which must be submitted by the case manager) or no waiver, which allows uploading of the request via MITS.
5. Read the statement regarding the understanding of privacy and signature requirements. Ensure the consumer or authorized representative signs and dates the form to confirm the information's accuracy.
6. Move to the provider information section. Fill out the first name, middle initial, and last name of the provider or agency. Include the Ohio Medicaid provider number, national provider identifier (NPI) number, and the ordering physician's name along with their NPI number.
7. Complete the ODA case manager information if applicable. Input the case manager's name, phone number with extension, and email address, ensuring all details are correct.
8. Once all sections are completed, review the form for accuracy. Ensure every required field is filled out correctly.
9. Finally, after reviewing, save any changes made to the form. You may also choose to download, print, or share the completed form as needed.

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