Odm 06723 2025

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The document is an authorization form from the Ohio Department of Medicaid that allows an applicant or recipient to designate a representative to act on their behalf in matters related to Medicaid. It includes sections for personal information, the scope of authority granted to the representative, and consent for the use and disclosure of protected health information (PHI). The form requires signatures from both the applicant/recipient and the authorized representative, ensuring confidentiality and compliance with privacy regulations.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (71 Votes)
2014	4.3 Satisfied (55 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How to check if your Medicaid is active online?

Log into your states Medicaid portal Many states have online portals where you can check your Medicaid coverage status. If you already created an account when you applied, log in to see any updates or changes to your status.

How do I check if my Ohio Medicaid is active?

Ohioans currently enrolled in Medicaid should take steps to ensure that their information is up to date: Check the status of your coverage using the Ohio Benefits Self Service Portal at benefits.ohio.gov.

What is the address for Medicaid claims in ohio?

Check the status of your coverage using the Ohio Benefits Self Service Portal at benefits.ohio.gov. Update your address on the Department of Medicaid website.

Can I check my Ohio Medicaid status online?

Your Medicaid benefits will need to be renewed annually and you will be notified when it is time to renew. Click here for more information about the renewal process.

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