Odm 07000 2026

1. Click ‘Get Form’ to open the odm 07000 in the editor.
2. Begin with SECTION A: IDENTIFYING INFORMATION FOR APPLICANT/PATIENT. Fill in the applicant's last name, first name, street address, city, state, and zip code. Ensure you include the date of birth and social security number accurately.
3. Indicate whether the applicant is a Medicaid recipient and provide details about their managed care plan if applicable. Complete the hospital name and discharge planner's contact information.
4. Move to SECTION B: DIAGNOSIS OF SERIOUS MENTAL ILLNESS. Answer questions regarding adverse PASRR determinations and provide necessary diagnoses as required.
5. In SECTION C: CERTIFICATION FOR HOSPITAL EXEMPTION, ensure that a physician certifies all criteria are met by providing their printed name, license number, signature, and date.
6. Finally, complete SECTION D: IDENTIFYING INFORMATION FOR THE NURSING FACILITY by filling in the nursing facility's details and expected admission date.

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