Get Oh Odm 03528 2021-2026

The OH ODM 03528 form is essential for accessing Healthchek services provided by Ohio’s Medicaid program for children and pregnant individuals. This guide will help you navigate the process of completing the form online, ensuring you provide the necessary information to receive the services your child or you may need.

Follow the steps to easily complete the OH ODM 03528 form online.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin with the 'Your Information' section. Fill in your first name, last name, case number, date of birth, street address, city, apartment number (if applicable), state, zip code, and email address.
3. Next, move to the 'Your Child’s Information' section. Here, enter your child’s name, social security number or Medicaid billing number, and any additional children’s information as necessary.
4. Indicate whether your child is enrolled in a Medicaid managed care plan. If so, provide the plan name or select 'No'.
5. Proceed to the 'Healthchek Screening Services' section. Check all applicable services that you or your child would like to receive, such as medical exams, vision exams, and mental health exams.
6. In the 'Healthchek Treatment Services and Transportation to Health Care Appointments' section, check any desired additional services, such as a list of doctors or transportation assistance.
7. Answer the questions regarding your child's health history, including lead poisoning tests and immunization status.
8. In the 'Support Services' section, check any additional services you are interested in, such as WIC or other support services.
9. Finally, review all entered information for accuracy. If everything is correct, sign and date the acknowledgment section at the bottom of the form.
10. Once completed, save your changes. You can then download, print, or share the form as necessary.

Complete your OH ODM 03528 form online to access essential Healthchek services today.