Ohio medicaid health insurance 2026

1. Click ‘Get Form’ to open the Ohio Medicaid Health Insurance Fact Request (ODM 06614) in the editor.
2. Begin by filling out the Provider Information section. Enter the Provider Number, Provider Name, Contact Person, Phone Number, Email Address, and Fax Number as required.
3. Next, move to the Recipient Information section. Input the Patient(s) Name and Medicaid Billing Number. Ensure you also provide the Patient’s Phone Number.
4. In this section, specify the Name of Insurance and complete the address fields: Address, City, State, and Zip Code.
5. Fill in details for the Policy Holder including their Name, Policy Number or Medicare Number, Policy Group Number, and Social Security Number (SSN).
6. Lastly, include any additional information such as payment dates from health insurance other than Medicaid or Medicare and any comments before submitting.

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