Use the links below to access, print, and complete the authorization form. A new form, Standard Authorization Form (Form Number: ODM 10221), is now available from the Ohio Department of Medicaid.We want to help you find the information you need. You must complete a separate authorization for each minor patient and for each adult caregiver. Minor Patient's Name. DOB. Cuyahoga DD Family Supports Program equipment requests will now be made through a simplified form online. (Client, Patient or Personal Representative).