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Odm 07216 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the Identifying Information section. Enter the individual's name, Medicaid ID number, date of birth, and contact details for both the prescriber and provider.
- In the Certification section, mark whether this is an initial request, a renewal, or a revision. Provide diagnosis codes and dates of evaluations as required.
- Complete the blood gas study results for at rest, ambulating, and sleeping conditions. Ensure you include PO2 levels and saturation percentages along with their respective dates.
- Indicate the estimated length of need by selecting either Group I or Group II criteria based on the patient's condition.
- Specify equipment needs in the Specifications section by choosing between stationary or portable systems and detailing flow rates and interfaces.
- Finally, have the prescriber complete the Attestation section by signing and dating it to confirm accuracy.
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Related links
ODM 07216 (Rev. Ohio Department of Medicaid. Free or low-cost insurance from Medicaid for adults and children (614) 466-2585 Toll Free: (877) 868-3874 call 1
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