Ohio Department of Medicaid Forms

This form is used for reporting changes for medical assistance in Ohio.

This form is used for individuals participating in the Specialized Recovery Services Program in Ohio. It outlines the agreement and responsibilities of the individual in the program.

This Form is used for applying for the Ohio Medicaid Reference File - Fee Schedule. It is a required document for healthcare providers in Ohio who want to participate in the Medicaid program and receive reimbursement for their services.

This form is used for registering for training programs in Ohio.

This form is used in Ohio for reporting pregnancies.

This Form is used for applying for health coverage and financial assistance in Ohio.

This Form is used for attestation purposes by managed care organizations in Ohio.

This Form is used for hospitals in Ohio to request exemption from preadmission screening notification.

This form is used for requesting data from the Privacy Board in Ohio.

This form is used for requesting an amendment to protected health information (PHI) in the state of Ohio.

This form is used for requesting an accounting of the disclosure of your protected health information in the state of Ohio.

This Form is used for requesting an amendment to protected health information (PHI) in Ohio.

This form is used as an addendum to the Medicaid Buy-In for Workers with Disabilities (MBIWD) program in Ohio. It includes additional information that needs to be provided with the application.

This form is used for making a decision on your request for a hardship exemption in the state of Ohio.

This form is used for obtaining a Certificate of Medical Necessity specifically for wearable Cardioverter-Defibrillators in the state of Ohio.

This document provides information about Healthchek and pregnancy-related services in Ohio.

This document is a form used in Ohio for the Drug Utilization Review Committee Conflict of Interest Policy. It outlines the policy regarding conflicts of interest in the committee.

This form is used for obtaining a certificate that verifies the destruction of data in Ohio. It ensures the secure disposal of sensitive information to protect against data breaches.

This document describes the Conflict of Interest Policy for the Drug Utilization Review Board in Ohio. It outlines guidelines and procedures to prevent conflicts of interest within the board.

This form is used for applying as a Managed Care Entity (MCE) in Ohio and provides options for both out-of-network providers and managed care-only providers.

This form is used for the Pharmacy and Therapeutics Committee in Ohio to disclose and address conflicts of interest among its members. It helps ensure transparency and integrity in the committee's decision-making process.

This Form is used for the Pharmacy and Therapeutics Committee Conflict of Interest Policy for Interested Party Guest Speakers in Ohio.

This Form is used for Ohio residents to declare the medical necessity of bathing seats.

This form is used for designating a trading partner for electronic transactions related to healthcare claims processing in the state of Ohio.

This form is used for referring individuals in Ohio for a review of their continuing eligibility for Medicaid.

This form is used for requesting prior authorization for substance use disorder services in Ohio.