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Form ODM03258 "Healthchek and Pregnancy Related Services

Form ODM03258 "Healthchek and Pregnancy Related Services 2026

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4.8 out of 5

175 votes

The document provides information about Ohio's Medicaid program, specifically the Healthchek services for children up to 21 years old. It outlines the importance of regular health screenings, treatment services, and support available through Healthchek, including prenatal exams for mothers and various health assessments for children. The document also details how to access these services, the role of Healthchek Coordinators, and the process for obtaining prior approval for certain treatments.

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How to use or fill out Form ODM03258 'Healthchek and Pregnancy Related Services'

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information in the 'Your Information' section. Fill in your first name, last name, case number, date of birth, street address, city, state, zip code, email, and telephone number.
Next, provide details for your child or children under the 'Your Child’s Information' section. Include each child's name and their respective SSN or Medicaid billing number.
Indicate whether your child is enrolled in a Medicaid managed care plan by selecting 'Yes' or 'No' and providing the plan name if applicable.
In the 'Healthchek Screening Services' section, check all services you or your child would like to receive. This includes medical exams and screenings.
Complete the 'Healthchek Treatment Services and Transportation to Health Care Appointments' section by checking any additional services needed.
Finally, review all information for accuracy before signing and dating the acknowledgment section at the bottom of the form.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (175 Votes)
2018	4.4 Satisfied (44 Votes)

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Does Medicaid need proof of pregnancy?

You will need to contact your local Medicaid office to find out what they require for Medicaid qualification documentation, but most offices require the following: Proof of pregnancy. Proof of citizenship, if a legal US resident ( and identification documentation such as a birth certificate or social security card)

What documents does Medicaid ask for?

What documents and information do you need for your Medicaid application? Your name and date of birth. Your Social Security number. Your monthly payment amounts for rent, mortgage, or utilities. Proof of citizenship or immigration status. Proof of income, like paystubs or W-2s.

Do I have to tell Medicaid Im pregnant?

If you report your pregnancy, you may be eligible for free or low-cost coverage through Medicaid or the Childrens Health Insurance Program (CHIP). If youre found eligible for Medicaid or CHIP, your information will be sent to the state agency, and you wont be given the option to keep your Marketplace plan.

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What does Medicaid cover for pregnancy in Ohio?

Medicaid eligibility levels for parents are much more restrictive than those related to pregnancy, which means that in all states some new parents no longer qualify for Medicaid after the postpartum period, but there is a divide in access to coverage between expansion and non-expansion states.

What is HealthChek?

Info: All pregnancy related services are covered. Services include: education, care coordination, counseling, high risk monitoring, nurse midwife services, preconception care, prenatal care, ultrasounds, prenatal risk assessment, delivery, and transportation.

Do I need proof of pregnancy for Medicaid?

0:06 2:56 Youll need is proof of pregnancy. So where can you get this proof. First youll need to take a homeMoreYoull need is proof of pregnancy. So where can you get this proof. First youll need to take a home pregnancy. Test while this isnt enough on its own its a good starting.

Form ODM03258 "Healthchek and Pregnancy Related Services 2026

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How to use or fill out Form ODM03258 'Healthchek and Pregnancy Related Services'