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Form ODM03620 Exiting Information and Forwarding Instructions From Long-Term Care Facility Operators / Providers (Nfs and Icfs-Mr) Discontinuing Participation in the Ohio Medicaid Program - Ohio
What Is Form ODM03620?
This is a legal form that was released by the Ohio Department of Medicaid - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is ODM03620?
A: ODM03620 is a form for exiting information and forwarding instructions from long-term care facility operators/providers in Ohio.
Q: Who is this form for?
A: This form is for long-term care facility operators/providers in Ohio, including Nfs and Icfs-Mr.
Q: What is the purpose of this form?
A: The purpose of this form is to provide information and instructions when a long-term care facility operator/provider is discontinuing participation in the Ohio Medicaid Program.
Q: What does the form require?
A: The form requires the facility operator/provider to provide various information such as contact details, resident list, outstanding claims, and forwarding instructions.
Form Details:
- Released on July 1, 2014;
- The latest edition provided by the Ohio Department of Medicaid;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of Form ODM03620 by clicking the link below or browse more documents and templates provided by the Ohio Department of Medicaid.
Download Form ODM03620 Exiting Information and Forwarding Instructions From Long-Term Care Facility Operators / Providers (Nfs and Icfs-Mr) Discontinuing Participation in the Ohio Medicaid Program - Ohio
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