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FORMS

Fill-in Forms Instructions

GENERAL

On-Line Security Request (Security Affidavit) (fill-in)

Vacancy Registry Data Collection Form

HEALTH AND SAFETY

Continuing Education (Nursing) Application

COUNTY BOARDS

2008-09 Individual Attendance Record Template (doc)

Registration and Certification

INDIVIDUAL OPTIONS (IO) WAIVERS

Home and Community Based Services (HCBS) Waiver Initial Application

Adding a Service

Becoming a new Provider

LEVEL ONE WAIVER

Level One Prescreening Tool

Informal Respite Services Forms, Documents Family Member and Limited Provider

Things You Need to Know About Me

Incidents Adversely Affecting Health and Safety & Behavior Support

Adding a Service

Becoming a new Provider

LEVEL ONE WAIVER ENROLLMENT

Notification of Individual Change in Status (fill-in)

Initial Waiver Application (fill-in)

Initial Enrollment Checklist

Redetermination Application-No Significant Change in Condition (fill-in)

Redetermination Application-Significant Change in Condition (fill-in)

Designation of Local Match Form

Forms and Instructions for Completion of Level Of Care Packet

HCBS Waiver Referral Form (DHS 2399)

Waiver Packet Checklist

Protective Level of Care-Attachment B

Protective Level of Care Review Form

Functional Assessment: Age 6-8 Attachment C

Functional Assessment: Age 9-11 Attachment D

Functional Assessment Age 12-15 Attachment E

Functional Assessment Age 16+ Attachment F

Freedom of Choice Documentation

Medical Evaluation

Psychological Evaluation

Notice of Approval for Assistance (DHS 4074)

MEDICAID

Ohio Developmental Disability Profile (The Questionnaire)

PRE Admission Screening and Resident Review (PASRR) FORMS

PRIOR AUTHORIZATION

Individual Request Form (07-17-08)

Prior Authorization Attachment A: Budget Information

Prior Authorization County Board Approval Sheet

Prior Authorization County Board Checklist

PROVIDER BILLING

EDI Trading Partner Form

EDI Trading Partner Agreement

Provider Request for Association with a Billing Agent

Forms and Instructions

PROVIDER CERTIFICATION FORMS

Ohio Health Plan Provider Enrollment Application/Agreement Instructions (ODJFS-6751) for Organizations

IRS W-9 Tax Identification form

Electronic Media Notification (ODJFS 6301) (fill-in)

MORE Registration and Certification FORMS

PROVIDER CERTIFICATION FORMS - LEVEL 1 WAIVER

Ohio Health Plan Provider Enrollment Application/Agreement (ODJFS 6750) – Individual Practitioners

PROVIDER COMPLIANCE REVIEW FORMS

General Compliance Documents

Pre-Review Documents

Individual Options Waiver Provider Review Documents

Level One Waiver Provider Review

Post Review Documents

TITLE XX FORMS

Application for Eligibility Determination/Redetermination

Unit of Service Log

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