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Click ‘Get Form’ to open the odm 06723 in the editor.
Begin by filling out Section 1 with your personal information, including your name, Medicaid Billing Number or SSN, and address details. Ensure all fields are completed accurately.
Designate your authorized representative by entering their name, contact information, and title. Specify the duration of this authorization clearly.
Select the actions you authorize your representative to perform on your behalf. You can choose from options like assisting with applications or representing you at hearings.
In Section 2, provide details for the authorization of protected health information (PHI). Fill in necessary identifiers such as case number and date of birth.
Review all entries for accuracy before signing. Both you and your authorized representative must sign and date the form for it to be valid.
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What is an authorized representative for ohio benefits?
Your Medicaid benefits will need to be renewed annually and you will be notified when it is time to renew.
Do you have to renew Ohio Medicaid every year?
An authorized representative can be any person you designate, hire, or contract with to complete, update, or make corrections to Section 2 (or Supplement B, Reverification and Rehire) on your behalf, such as personnel officers, foremen, notaries public, agents, or anyone acting directly or indirectly in your agents
What is ohios Medicaid called?
An authorized representative (AR) is a person or organization who can act on behalf of an individual to help apply for and/or keep Medicaid, SNAP and/or TANF/OWF coverage. Naming an AR is optional and can be time limited.
What is Ohio Medicaid called?
Broadly, there are four major eligibility groups covered by most states: children, adults with disabilities, aged adults, and nondisabled adults.
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