Forms

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Contracting and Practice Changes

Member-Related Forms

Pharmacy Prior Authorization

Medical and Other Prior Authorization

Claims

Appeals

Dental

Pregnancy 

Abortion, Hysterectomy and Sterilization 

Forms

  • ODM Abortion Certification Form – Submit this form to certify that the service meets the Ohio Department of Medicaid’s criteria to receive Medicaid reimbursement.
  • ODJFS Acknowledgement of Hysterectomy Information – Submit this form to document acknowledgment that a patient received hysterectomy information prior to the procedure(s), in compliance with Ohio Department of Job and Family Services (ODJFS) requirements.
  • ODJFS Consent for Sterilization Form – Submit this form to certify a patient received sterilization information and gave consent prior to the procedure(s), in compliance with ODJFS requirements.

Instructions 

Fraud, Waste and Abuse