Ohio Medicaid Insulin Pump Certificate 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Identifying Information section. Enter the individual's name, date of birth, height, weight, and contact details. Ensure that you include the Medicaid ID and provider numbers accurately.
3. Move to the Certification section. Mark all applicable diagnosis codes and symptoms related to diabetes. This includes checking boxes for conditions like high glycated hemoglobin levels or a history of severe glycemic excursions.
4. In the Certification for Additional Rental or Purchase section, indicate whether you are requesting a rental or purchase. Fill in the requested dates and any prior authorization numbers if applicable.
5. Finally, complete the Attestation section by having the prescriber sign and date it, confirming that all information provided is accurate.

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