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Get OH ODM 07000 2014-2024

T clearly. Submit the original notification to the nursing facility and a copy to the local PASSPORT Administrative Agency (PAA) prior to the discharge from the hospital. This form must be completed fully in order for the Nursing Facility to accept payment for nursing facility services. Incomplete forms will be returned. SECTION A: IDENTIFYING INFORMATION FOR APPLICANT/PATIENT Last Name First Name Street Address MI City State Ohio County of Residence Sex Social Security # Zip Date of B.

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