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Get Odm03620 Fillable 2014-2025
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How to fill out the Odm03620 Fillable online
The Odm03620 Fillable form is essential for long-term care facilities disbanding their participation in the Ohio Medicaid program. This guide will provide you with step-by-step instructions to fill out the form accurately, ensuring compliance with the necessary regulations.
Follow the steps to complete the Odm03620 Fillable form effectively.
- Press the ‘Get Form’ button to access the Odm03620 Fillable form and open it in your chosen editing platform.
- In Section 1, provide the facility name, address, and the exiting operator/provider information, including the last day of operation and their legal entity name.
- In Section 2, enter the exiting operator/provider identifiers, including the Medicaid legacy number, National Provider Identifier (NPI), CMS certification number, and federal I.D.
- For Section 3, fill in the mailing and contact information. Ensure that the mailing address is accurate and does not include post office box or drop box addresses. Provide a contact person, their email address, telephone number, and fax number.
- In Section 4, input the ‘Pay To’ name and the payment address, making sure it is where payment correspondence will be sent. Include the federal I.D. for the ‘Pay To’ entity and contact information for questions related to payment.
- Section 5 allows for any additional information or instructions regarding the exiting entity. Use this space as needed.
- Finally, complete Section 6 by providing the authorized signature, printed name, title, date, and contact information. Ensure all details are correct for a successful submission.
- Once you have filled out the form, you can save your changes, download the completed document, print it, or share it with the relevant coordinators.
Complete your Odm03620 Fillable form online today and ensure your compliance with the Ohio Medicaid program.
Updating your income with Ohio Medicaid requires you to report the changes through an updated application. The Odm03620 Fillable form is ideal for accurately reflecting your new income details. Timely updates help maintain your benefits without disruptions.
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