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You are a Provider

Provider Forms
The Provider Forms Directory holds a list of Provider forms which are supplied by the Ohio Home Care Program. They are available in Word format and can be saved to your computer.

Provider Forms Directory

The following forms are some of the most frequently requested by Providers.

Forms

Request for Provider

This form may be used when a Consumer is requesting personal care assistance. The person requested must first apply to become an OHC Provider.

Tax Affidavit (pdf version) (word version)
This is an affidavit of tax payment compliance for Non-Agency-Employed ODM-Administered Waiver Service Providers.

PCA DOCUMENTATION
PCA Providers must retain documentation containing consumer-identifying information (like what is seen on the EXAMPLE FACE SHEET), as well as documentation of the care provided during each visit. Three EXAMPLE Visit records are listed below. Upon ending services to the consumer the PCA is required to complete a DISCHARGE SUMMARY.
Face Sheet and Instructions
PCA Activity Once a Day Visit Timesheet
PCA Daily Weekly Visit Record 2011
PCA Weekly Visit Documentation Sheet (page one of two)
PCA Daily Visit Record  - Daily Narrative Note (page two of two)
PCA Daily Visit Record – Checklist Style
PCA Discharge Summary

Consumer Needs Checklist (pdf version) (word version)
This form indicates a Consumer's needs and frequency assistance is required.

Provider Services Calendar (pdf version) (word version)
This form is used to track visits and units for each day of the month.

Authorization Agreement

This form is used when a Provider selects Direct Deposit option for reimbursement.

Provider Change of Information Form

Provider information changes are now exclusively online and paper forms are no longer accepted. To change your information please access the MITS system here and login to your account or register.

Unpublished Provider Data Option (pdf version) (word version)
Providers may elect to have their Provider data such as their name, address, phone number and fax number unpublished and unavailable to the public.

Voluntary Termination Form
Providers can use this form to voluntarily terminate their Medicaid Provider agreement and relinquish their Provider Number.
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Skilled Nurse Sample Documentation Forms
Skilled Nurses are required to obtain signed physician orders every 60 days and as needed.  The CMA-POC 485 format may be used to meet this requirement but does not contain all the required consumer data fields.  Please refer to the rules for specific consumer data which requires to be retained by the skilled nurse provider. LPNs require the supervision of services by a DIRECTING REGISTERED NURSE.  These visits require documentation and both the LPN and RN should retain copies of this document.  An EXAMPLE of a Supervisory Notes is listed below.  Skilled Nurses are required to maintain medication administration records according to the Ohio Board of Nursing rules.  A sample MEDICATION ADMINISTRATION RECORD is listed below.  Two EXAMPLES of skilled nurse visit documentation is listed below as references.  A EXAMPLE of a Discharge Summary is included relating the required information needed when ending services with a consumers.

CMS-POC 485 Instructions
CMS-POC 485 Example Page (pdf version) (word version)
CMS-POC 485 Form (pdf version) - (word version)
CMS-POC 485 60-Day Calculator (enter 1st day of recertification period +59)
Supervisory Visit Note
Medication Administration Form
Skilled Nurse Visit Record – Version 1
Skilled Nurse Visit Record – Version 2
Skilled Nurse Discharge Summary (pdf version) (word version)

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Private Duty Nursing Services Request
This form can be filled out to request private duty nursing services.

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Certificate of Medical Necessity - Home Care Certification Form
This form is used to certify the needs for Increased Home Health Services and/or Private Duty Nursing Services.

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HealthChek Referral Form
These forms are used for authorization for the HealthChek program.

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Personal Care Aide Service Decline Form (pdf version) (word version)
Providers may elect not to furnish specific services. Provider must notify CareStar in writing of the services the provider elects not to furnish.
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Consumer & Provider Prevention Packet (pdf version) (word version)
Weekly Fall Risk Checklist (pdf version) (excel version)
Monthly Fall Risk Checklist (pdf version) (excel version)
Wheelchair Version Weekly Fall Risk Checklist (pdf version) (word version)