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Ohio Department of Medicaid Forms Library

Order Forms/Email Requests

Form Number	Order Form	Form Name
ODM 07216	(ORDER FORM)	Application for Health Coverage & Help Paying Costs
ODM 03528	(ORDER FORM)	Healthchek & Pregnancy Related Services Information Sheet
ODM 10129	(ORDER FORM)	Long-Term Services and Supports Questionnaire (LTSSQ) - Email Request
ODM 02399	(ORDER FORM)	Request for Medicaid Home and Community Based Services (HCBS)

{"data":[["s","h","s","s"],["File Name","URL","Language","Form Name"],["ODM 10279","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10279Fillx.pdf","English","NOTICE OF PROVIDER EXCEPTION"],["ODM 10119i","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10119i.pdf","English","INSTRUCTION FOR COMPLETING THE ODM 10119 FIRST TIER DOWN STREAM AND RELATED ENTITY (FDR) AGREEMENT OR SOLE SOURCE CONTRACT NOTIFICATION"],["ODM 10300","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10300Fillx.pdf","English","ZYNTEGLO TREATMENT REQUEST"],["ODM 10301","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10301Fillx.pdf","English","ZOLGENSMA TREATMENT REQUEST"],["ODM 10302","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10302Fillx.pdf","English","SKYSONA TREATMENT REQUEST"],["ODM 10277","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10277Fillx.pdf","English","CERTIFICATE OF MEDICAL NECESSITY: CONTINUOUS GLUCOSE MONITORING SYSTEMS"],["ODM 10295","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10295Fillx.pdf","English","MANAGED CARE ENTITY (MCE) OUT-OF-NETWORK AND SINGLE CASE AGREEMENT PROVIDER APPLICATION"],["ODM 10294","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10294Fillx.pdf","English","SUBSTANCE USE DISORDER RESIDENTIAL TREATMENT NOTIFICATION OF ADMISSION"],["ODM 10280","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10280FillX.pdf","English","Attestation of Private Transportation Vendor Compliance"],["ODM 10189","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10189Fillx.pdf","English","Drug Utilization Review Committee Conflict of Interest Policy"],["ODM 10282","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10282Fillx.pdf","English","MANAGED CARE ENTITY (MCE) OUT-OF-NETWORK PROVIDER APPLICATION"],["ODM 10283","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10283Fillx.pdf","English","Ohio Medicaid Provider Agreement"],["ODM 10286","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10286Fillx.pdf","English","Drug Utilization Review Board Conflict of Interest Policy"],["ODM 10284","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10284Fillx.pdf","English","Pharmacy and Therapeutics Committee Conflict of Interest Policy"],["ODM 10285","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10285Fillx.pdf","English","Pharmacy and Therapeutics Committee Conflict of Interest Policy Interested Party Guest Speakers"],["ODM 10281","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10281Fillx.pdf","English","Certificate of Data Destruction"],["ODM 06613","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06613fillx.pdf","English","Accident/Injury Insurance Information"],["ODM 10108","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10108fillx.pdf","English","Provider Information Update"],["ODM 10273","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10273Fillx.pdf","English","Voluntary Termination of Ohio Medicaid Provider Agreement"],["ODM 06613i","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06613i.pdf","English","Accident/Injury Insurance Information - Instructions"],["ODM 10252","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10252fillx.pdf","English","Acknowledgement of Terms and Conditions Governing the Presumptive Eligibility Determinations"],["ODM 03199","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03199fillx.pdf","English","Acknowledgment of Hysterectomy Information"],["ODM 03199","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM03199SPA.pdf","Spanish","Acknowledgment of Hysterectomy Information"],["ODM 10198","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10198fillx.pdf","English","Addendum to ODM provider agreement for ventilator services in nursing facilities"],["ODM 06766","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06766fillx.pdf","English","Adjustment Request for Hospital Only ODM 06766"],["ODM 06767","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06767fillx.pdf","English","Adjustment Request for ODM 06767"],["ODM 07407","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07407.pdf","English","Affidavit of Identity for a Child Age 16 Years Or Less"],["ODM 07407","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM07407SPA.pdf","Spanish","Affidavit of Identity for a Child Age 16 Years Or Less"],["ODM 02218","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02218.pdf","English","Affidavit of Tax Payment Compliance for Non Agency Employed Home Choice Demonstration Program Service Providers"],["ODM 02219","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02219fillx.pdf","English","Affidavit of Tax Payment Compliance For Non-Agency ODM-Administered Waiver Service Providers"],["ODM 10220","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10220Fillin.pdf","English","ANNUAL PROGRAM INTEGRITY REPORT FOR MANAGED CARE ORGANIZATIONS Calendar Year 2020 "],["ODM 01959","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01959fillx.pdf","English","APPEAL SUMMARY FOR MANAGED CARE ENTITIES"],["ODM 07216","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07216fillx.pdf","English","Application for Health Coverage & Help Paying Costs"],["ODM 07216","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM07216SPA.pdf","Spanish","Application for Health Coverage & Help Paying Costs"],["ODM 07103","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07103.pdf","English","Application for Help With Medicare Expenses (With Voter Registration)"],["ODM 07103","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07103.pdf","Spanish","Application for Help With Medicare Expenses (With Voter Registration)"],["ODM 10226","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10226Fillx.pdf","English","Attestation"],["ODM 03749","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03749.pdf","English","Authorization for Certificate of Group Health Plan Coverage"],["ODM 03749","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM03749SPA.pdf","Spanish","Authorization for Certificate of Group Health Plan Coverage"],["ODM 03397","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03397fillx.pdf","English","Authorization for the Release or Use of Protected Health Information (PHI)"],["ODM 06305","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06305fillx.pdf","English","Authorization to Post Trading Partner Information"],["ODM 07140","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07140.pdf","English","Availability of Hardship Exemption"],["ODM 07140","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM07140SPA.pdf","Spanish","Availability of Hardship Exemption"],["ODM 07302","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07302fillx.pdf","English","Basic Medical"],["ODM 01902","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01902fillx.pdf","English","Certificate of Medical Necessity : Ventilators"],["ODM 07137","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07137fillx.pdf","English","Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services"],["ODM 03411","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03411fillx.pdf","English","CERTIFICATE OF MEDICAL NECESSITY WHEELCHAIRS"],["ODM 01913","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01913fillx.pdf","English","Certificate of Medical Necessity/Request For Need Verification: General Medical Supplies And Equipment"],["ODM 02900","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02900fillx.pdf","English","Certificate of Medical Necessity: Apnea Monitors"],["ODM 10274","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10274Fillx.pdf","English","Certificate of Medical Necessity: Bathing Seats"],["ODM 01905","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01905fillx.pdf","English","Certificate of Medical Necessity: Compression Garments"],["ODM 01907","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01907fillx.pdf","English","Certificate of Medical Necessity: Enteral and Parenteral Nutrition"],["ODM 01915","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01915fillx.pdf","English","Certificate of Medical Necessity: Hearing Aids"],["ODM 10229","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10229PDFillx.pdf","English","Certificate of Medical Necessity: High-Frequency Chest Wall Oscillation Devices"],["ODM 02910","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02910fillx.pdf","English","Certificate of Medical Necessity: Hospital Beds And Bed Accessories"],["ODM 02912","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02912fillx.pdf","English","Certificate of Medical Necessity: Incontinence Items"],["ODM 07136","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07136fillx.pdf","English","Certificate of Medical Necessity/Prescription External Insulin Pump"],["ODM 01901","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01901fillx.pdf","English","Certificate of Medical Necessity: Lactation Pumps"],["ODM 07134","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07134fillx.pdf","English","Certificate of Medical Necessity: Osteogenesis Stimulators"],["ODM 01909","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01909fillx.pdf","English","Certificate of Medical Necessity: Oxygen"],["ODM 02929","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02929fillx.pdf","English","Certificate of Medical Necessity: Pneumatic Compression Devices And Accessories"],["ODM 01903","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01903fillx.pdf","English","Certificate of Medical Necessity: Positive Airway Pressure Devices"],["ODM 02904","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02904fillx.pdf","English","Certificate of Medical Necessity: Pressure-Reducing Support Surfaces"],["ODM 03401","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03401fillx.pdf","English","Certificate of Medical Necessity: Pulse Oximeters"],["ODM 02924","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02924fillx.pdf","English","Certificate of Medical Necessity: Speech-Generating Devices"],["ODM 01912","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01912fillx.pdf","English","Certificate of Medical Necessity: Therapeutic Footwear For Individuals With Diabetes"],["ODM 03402","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03402fillx.pdf","English","Certificate of Medical Necessity: Transcutaneous Electrical Nerve Stimulator (TENS)"],["ODM 10275","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10275Fillx.pdf","English","Certificate of Medical Necessity: Wearable Cardioverter-Defibrillators"],["ODM 01960","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01960fillx.pdf","English","Certification Of Necessity For Non-Emergency Transportation By Ground Ambulance"],["ODM 03452","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03452fillx.pdf","English","Certification Of Necessity For Transportation By Wheelchair Van"],["ODM03515i","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03515-I.docx","English","Completing Pregnancy Related Services Implementation Plan - Instructions"],["OMB 0937 0166","https://opa.hhs.gov/sites/default/files/2022-07/consent-for-sterilization-english-2025.pdf","English","Consent for Sterilization"],["OMB 0937 0166","https://medicaid.ohio.gov/static/Resources/Publications/Forms/OMB09370166i.pdf","English","Consent for Sterilization - Instructions"],["ODM 10270","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10270Fillx.pdf","English","County Response to Medicaid Quality Control(MEQC) Case Finding"],["OMB 0937 0166","https://opa.hhs.gov/sites/default/files/2022-07/consent-for-sterilization-spanish-2025.pdf","Spanish","CONSENTIMIENTO PARA LA ESTERILIZACI�N"],["ODM 10225","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10225Fillx.pdf","English","DECONFLICTION REQUEST"],["ODM 06306","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06306fillx.pdf","English","Designation of an 835 or 834/820 Trading Partner"],["ODM 06306i","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06306i.pdf","English","Designation of an 835 Or 834/820 Trading Partner - Instructions"],["ODM 06723","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06723fillx.pdf","English","Designation of Authorized Representative"],["ODM 06723","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM06723-SPApdfillx.pdf","Spanish","Designation of Authorized Representative"],["ODM 02392","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02392fillx.pdf","English","Designation of Authorized Representative for Home Care Attendant Services"],["ODM 01984","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01984.pdf","English","Developmental Center Cost Report"],["ODM 07124","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07124fillx.pdf","English","Eligibility Information Worksheet for Nursing Homes And HCBS Waivers"],["ODM 03620","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03620.pdf","English","Exiting Information and Forwarding Instructions From Long Term Care Facility Operators/Providers (NFs And ICFS/MR) Discontinuing Participation In the Ohio Medicaid Program"],["ODM 07212","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07212.pdf","English","Explanation of Qualified Medicaid Beneficiary"],["ODM 07212","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM07212SPA.pdf","Spanish","Explanation of Qualified Medicaid Beneficiary"],["ODM 09401","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM09401fillx.pdf","English","Facility Communication"],["ODM 03421","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03421.xls","English","Federally Qualified Health Center Cost Report"],["ODM 10238","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10238fillx.pdf","English","Health and Safety Action Plan"],["ODM 06614","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06614fillx.pdf","English","Health Insurance Fact Request"],["ODM 06614i","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06614i.pdf","English","Health Insurance Fact Request - Instructions"],["ODM 06612","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06612fillx.pdf","English","Health Insurance Information Sheet"],["ODM 03528","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03528fillx.pdf","English","Healthchek & Pregnancy Related Services Information Sheet"],["ODM 03528 (WORD)","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03528.docx","English","Healthchek & Pregnancy Related Services Information Sheet"],["ODM 03528","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM03528-spa-pdfillx.pdf","Spanish","Healthchek & Pregnancy Related Services Information Sheet"],["ODM 03528 (WORD)","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM03528-spa-Wordfillx.docx","Spanish","Healthchek & Pregnancy Related Services Information Sheet"],["ODM 03528","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Somali/ODM03528somfillx.pdf","Somali","Healthchek & Pregnancy Related Services Information Sheet"],["ODM 03528 (WORD)","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Somali/ODM03528som.docx","Somali","Healthchek & Pregnancy Related Services Information Sheet"],["ODM 03528","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Arabic/ODM03528arafillx.pdf","Arabic","Healthchek & Pregnancy Related Services Information Sheet"],["ODM03517","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03517.docx","English","Healthchek Services Implementation Plan"],["ODM 03517i","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03517i.pdf","English","Healthchek Services Implementation Plan - Instructions"],["ODM 10204","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10204fillx.pdf","English","Heightened Scrutiny Evidence Package"],["ODM 10171","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10171fillx.pdf","English","HEALTHCHEK AND PREGNANCY RELATED SERVICES INFORMATION SHEET FOR MEDICAID MANAGED CARE PLANS"],["ODM 10172","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10172fillx.pdf","English","Home and Community-Based Services (HCBS) Settings Evaluation Tool"],["ODM 10173","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10173fillx.pdf","English","Home and Community-Based Services (HCBS) Settings Verification Checklist"],["ODM 02390","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02390fillx.pdf","English","Home Care Attendant (HCA) Skilled Task Authorization"],["ODM 02389","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02389fillx.pdf","English","Home Care Attendant Medication Authorization"],["ODM 10239","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10239Fillx.pdf","English","Home Choice Application (State Funded Program)"],["ODM 07000","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07000fillx.pdf","English","Hospital Exemption From Preadmission Screening Notification"],["ODM 02213","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02213.pdf","English","Information Update"],["ODM 06723-I","https://medicaid.ohio.gov/static/Resources/Publications/Forms/06723i.pdf","English","Instruction for Completing the ODM 06723 Designation of Authorized Representative"],["ODM 10207i","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10207i.pdf","English","Instruction For Completing the ODM 10207 Pregnancy Risk Assessment Communication (PRAF)"],["ODM 03697","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03697fillx.pdf","English","Level of Care Assessment"],["ODM 10247","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10247Fillx.pdf","English","MAC Request"],["ODM 10267","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10267Fillx.pdf","English","MCO Pilot Request Template"],["ODM 10235","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10235Fillx.pdf","English","MCP - MEDICAID ADDENDUM"],["ODM 10231","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10231Fillx.pdf","English","MANAGED CARE ENTITY (MCE) - GROUP PROVIDER AFFILIATIONS - ATTACHMENT A"],["ODM 10234","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10234Fillx.pdf","English","MANAGED CARE ENTITY (MCE) - SERVICES PROVIDED - ATTACHMENT C"],["ODM 10113","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10113fillx.pdf","English","MCP/MCOP Reporting Document for Improper Disclosure of Protected Health Information (PHI)"],["ODM 10241","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10241Fillx.pdf","English","Medicaid County Transportation Profile"],["ODM 07220","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07220fillx.pdf","English","Medicaid Eligibility Review Verification Request Checklist"],["ODM 07220","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM07220SPA.pdf","Spanish","Medicaid Eligibility Review Verification Request Checklist"],["ODM 10218","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10218PDFillx.pdf","English","MEDICAID FRAUD REFERRAL"],["ODM 07316","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07316fillx.pdf","English","Medicaid Non Institutional Budget & Resource Computation Worksheet"],["ODM 02920","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02920fillx.pdf","English","Medicaid Provider Final Settlement : Part 1"],["ODM 02921","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02921fillx.pdf","English","Medicaid Provider Final Settlement : Part 2"],["ODM 02918","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02918fillx.pdf","English","Medicaid Provider Interim Settlement : Part 1"],["ODM 02919","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02919fillx.pdf","English","Medicaid Provider Interim Settlement : Part 2"],["ODM 10269","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10269Fillx.pdf","English","Medicaid Quality Control (MEQC) Case Finding Communicator"],["ODM 06653","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06653fillx.pdf","English","Medical Claim Review Request"],["ODM 06653i","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06653i.pdf","English","Medical Claim Review Request - Instructions"],["ODM 07308","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07308fillx.pdf","English","Mental Functional Capacity Assessment"],["ODM 01705","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01705fillx.pdf","English","Notice of Continued Enrollment In the Coordinated Services Program (CSP)"],["ODM 01718","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01718.pdf","English","Notice of Denial of Designated Provider or Pharmacy In the Coordinated Services Program (CSP)"],["ODM 04043","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM04043fillx.pdf","English","NOTICE OF DENIAL OF MEDICAL SERVICES BY YOUR MANAGED CARE ENTITY"],["ODM 04043","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM04043SPAfillx.pdf","Spanish","NOTICE OF DENIAL OF MEDICAL SERVICES BY YOUR MANAGED CARE ENTITY"],["ODM 04046","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM04046fillx.pdf","English","NOTICE OF DENIAL OF PAYMENT FOR MEDICAL SERVICES BY YOUR MANAGED CARE ENTITY"],["ODM 04046","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM04046SPAfillx.pdf","Spanish","NOTICE OF DENIAL OF PAYMENT FOR MEDICAL SERVICES BY YOUR MANAGED CARE ENTITY"],["ODM 01711","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01711fillx.pdf","English","Notice of Denial of Your Request to Terminate Membership in Your Managed Care Plan for \"Just Cause\" from the Bureau of Managed Care"],["ODM 07213","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07213fillx.pdf","English","Notice of Failure to Submit Resource Documentation for Resource Assessment"],["ODM 07335","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07335.pdf","English","Notice of Medicaid Overpayment"],["ODM 10102","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10102.pdf","English","Notice of Privacy Practices"],["ODM 01717","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01717fillx.pdf","English","Notice of Proposed Enrollment In the Coordinated Services Program (CSP)"],["ODM 04066","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM04066fillx.pdf","English","\"Notice of Reduction, Suspension, or Termination of Medical Services By Your Managed Care Entity\" "],["ODM 04066","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM04066SPAfillx.pdf","Spanish","\"Notice of Reduction, Suspension, or Termination of Medical Services By Your Managed Care Entity\" "],["ODM 07408","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07408fillx.pdf","English","Notice to Medicaid Estate Recovery of Pending Transfer of Property by Transfer on Death Deed"],["ODM 03245","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03245fillx.pdf","English","Notification of Third Party (Tort) Request Release"],["ODM 10228","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10228fillx.pdf","English","Nursing Facility Quarterly Ventilator Program Report"],["ODM 10193","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10193fillx.pdf","English","ODM 10193 Qualified Income Trust Verification"],["ODM 07160","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07160fillx.pdf","English","Ohio Breast & Cervical Cancer Project : Treatment Plan"],["ODM 07161","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07161fillx.pdf","English","Ohio Breast & Cervical Cancer Project Medicaid Application (With Voter Registration)"],["ODM 07161","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM07161SPA.pdf","Spanish","Ohio Breast & Cervical Cancer Project Medicaid Application (With Voter Registration)"],["ODM 01900","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01900.pdf","English","Ohio Health Plans Letter Template Approval Route Slip"],["ODM 07400","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07400.pdf","English","Ohio Medicaid Estate Recovery"],["ODM 07400","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM07400SPA.pdf","Spanish","Ohio Medicaid Estate Recovery"],["ODM 0293020","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02930.zip","English","Ohio Medicaid Hospital Cost Report Software"],["ODM 03623","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03623fillx.pdf","English","Ohio Medicaid Provider Agreement for Long Term Care Facilities"],["ODM 06755","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06755.pdf","English","Ohio Medicaid Provider Number Application for Managed Care Plans"],["ODM 06021","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM06021fillx.pdf","English","Ohio Medicaid Reference File : Fee Schedule Application"],["ODM 09405","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM09405fillx.pdf","English","Personal Needs Allowance Account Remittance Notice"],["ODM 10259","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10259Fillx.pdf","English","Pharmacy Industry Day Application"],["ODM 03622","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03622fillx.pdf","English","Preadmission Screening and Resident Review (PASRR) Identification Screen"],["ODM 10119","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10119Fillx.pdf","English","FIRST TIER DOWN STREAM AND RELATED ENTITY (FDR) AGREEMENT OR SOLE SOURCE CONTRACT NOTIFICATION"],["ODM03515","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03515.docx","English","Pregnancy Related Services Implementation Plan"],["ODM 10207","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10207fillx.pdf","English","Pregnancy Risk Assessment Communication (PRAF)"],["ODM 03534","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03534fillx.pdf","English","Prenatal Risk Notification"],["ODM 10184","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10184Fillx.pdf","English","Prior Authorization Compound Medications"],["ODM 10186","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10186Fillx.pdf","English","Prior Authorization Hepatitis C Treatment"],["ODM 10191","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10191Fillx.pdf","English","Prior Authorization OmniPod Insulin Pumps"],["ODM 10243","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10243Fillx.pdf","English","Prior Authorization Oral Medication Assisted Treatment of Opioid Use Disorder"],["ODM 10246","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10246Fillx.pdf","English","Prior Authorization Synagis"],["ODM 03197","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03197fillx.pdf","English","Prior Authorization: Abortion Certification"],["ODM 10159","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10159fillx.pdf","English","Privacy Board - Application For Waiver Or Alteration Of Authorization"],["ODM 10157","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10157fillx.pdf","English","Privacy Board Data Request"],["ODM 02376","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02376.pdf","English","Private Duty Nursing (PDN) Assessment"],["ODM 02373","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02373fillx.pdf","English","Private Duty Nursing (PDN) Assessment Outcome"],["ODM 02374","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02374fillx.pdf","English","Private Duty Nursing (PDN) Services Request"],["ODM 02398","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02398.pdf","English","Program of All Inclusive Care for the Elderly (PACE) Referral"],["ODM 03300","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03300fillx.pdf","English","Provider Reporting Number Application for Managed Care Plan (MCP) Providers"],["ODM 03630","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03630fillx.pdf","English","Referral Evaluation Criteria for Comprehensive Orthodontic Treatment"],["ODM 01958","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01958.pdf","English","Referral for Medicaid Continuing Eligibility Review"],["ODM 10203","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10203fillx.pdf","English","Report A Change For Medical Assistance"],["ODM 10257","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10257Fillx.pdf","English","Report of Pregnancy"],["ODM 01952","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01952.pdf","English","Request for Amendment to Protected Health Information (PHI)"],["ODM 03398","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03398.pdf","English","Request for an Accounting of Disclosure of Protected Health Information"],["ODM 10199","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10199fillx.pdf","English","Request For Approval Of Claim Specialty Care Transport (SCT) and Related Mileage"],["ODM 01950","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01950.pdf","English","Request for Contract Resources Template"],["ODM 10250","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10250fillx.pdf","English","Request for Information"],["ODM 10250","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM10250SPAfillx.pdf","Spanish","Request for Information"],["ODM 02399","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM02399fillx.pdf","English","Request for Medicaid Home and Community Based Services (HCBS)"],["ODM 02399","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM02399SPAfillx.pdf","Spanish","Request for Medicaid Home and Community Based Services (HCBS)"],["ODM 01904","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01904fillx.pdf","English","\"Request for Need Verification: Repair of Durable Medical Equipment (other than wheelchairs), Prostheses, or Orthotic Devices\""],["ODM 01953","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM01953.pdf","English","Request for Restriction of Use of Protected Health Information (PHI)\t\t"],["ODM 03523","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03523fillx.pdf","English","Request for Rx Prior Authorization\t\t"],["ODM 10192","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10192Fillx.pdf","English","Request for Rx Prior Authorization Long-Acting or Short-Acting Opioid Medication"],["ODM 10227","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10227fillx.pdf","English","Request To Participate In The ODM Nursing Facility Ventilator Program\t\t"],["ODM 07120","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07120.pdf","English","Residential State Supplement\t\t"],["ODM 07004","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07004.pdf","English","Social Summary Report for Disability Determination\t\t"],["ODM 10178","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10178Fillx.pdf","English","Specialized Recovery Services Program Handbook - Acknowledgement and Agreement\t\t"],["ODM 10221","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10221fillx.pdf","English","Standard Authorization Form\t\t"],["ODM 10221","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM10221-SPA-fillx.pdf","Spanish","Standard Authorization Form\t\t"],["ODM 10221I","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10221i.pdf","English","Standard Authorization Form Instructions"],["ODM 10221I","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM10221-I-spa.pdf","Spanish","Standard Authorization Form Instructions"],["ODM 10124","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10124.docx","English","State Healthchek Plan Referral"],["ODM 10244","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10244Fillx.pdf","English","STEP THERAPY EXEMPTION REQUEST"],["ODM 10276","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10276Fillx.pdf","English","Substance Use Disorder Services Prior Authorization Request"],["ODM 07405","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07405fillx.pdf","English","Third Party Affidavit of Birthplace or Nationality\t\t"],["ODM 07405","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM07405SPA.pdf","Spanish","Third Party Affidavit of Birthplace or Nationality\t\t"],["ODM 03246","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM03246fillx.pdf","English","TORT SUMMARY STATEMENT FOR MANAGED CARE ENTITIES (MCEs)"],["ODM 10140","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10140fillx.pdf","English","Training Registration"],["ODM 10253","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10253Fillx.pdf","English","Waiver Community Transition Services Authorization Template"],["ODM 07236","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM07236fillx.pdf","English","Your Rights and Responsibilities as a Consumer of Medicaid Health Coverage"],["ODM 07236","https://medicaid.ohio.gov/static/Resources/Publications/Forms/Spanish/ODM07236SPA.pdf","Spanish","Your Rights and Responsibilities as a Consumer of Medicaid Health Coverage"],["ODM 10259","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10259Fillx.pdf","English","Pharmacy Industry Day Application "],["ODM 10293","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10293Fillx.pdf","English","Ohio Average Acquisition Cost (OAAC) Appeal and Response"],["ODM 10292","https://medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10292Fillx.pdf","English","INFORMATION NEEDED TO DETERMINE THE MEDICAID SINGLE PHARMACY BENEFIT MANAGER DISPENSING FEE"],[""]],"errors":[],"meta":{"delimiter":",","linebreak":"\r\n","aborted":false,"truncated":false,"cursor":33685}}

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