¬ 24-Hour Hotline - 1-800-282-1784. 1. Fill the prescribed form with all the required details.How to fill out the Ohio Medicaid Adjustment Request Form ODM 06767? Gov(opens in a new window). Member Forms, Pension Benefit Applications, DROP Forms, Annuity Forms, Beneficiary and Survivor Forms, Disability Benefit Forms, Health Care Forms Provider Address - Enter the complete mailing address; including city, state and zip code, of the provider who received the Medicaid payment. Step 4: Click on the Save button. Use our Form Filler to fill out your form online and print it. Workout Guides in the PF App. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.