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Send ohio medicaid authorized representative form via email, link, or fax. You can also download it, export it or print it out.
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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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