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We have received several emails from individuals thanking us for providing the forms on this page. People have indicated that they have modified the forms for use by their facility. We are happy to provide the information and intend to continue to be the one stop resource for you. If there is something that you are looking for and you do not see it let us know by sending an email to ltcohio1@yahoo.com 

To view or download right click the icon for the selected item. Go to the top one -Open Link in New Window and left click on it to open it.


Preadmission Review -After Hours Coverage Schedule

PAA 3 will continue to provide weekend coverage until the HENS PASRR is ready to go live. The fax and phone numbers are unchanged – fax 419-222-8262 and phone 419-222-7723. The phone rings to an answering machine/voice mail which someone monitors and returns calls

7000 Hospital Exemption Form

Download 7000.pdf

3622 (PASRR screen)-Also called RR/ID

Download 3622.pdf

3697 (Level of Care Assessment)-Can be used if an MDS is not available. It can also be used by a hospital or home care agency to submit to Preadmission review for a level of care

Download 3697_Level_Of_Care_Assesment.pdf

7200 (Medicaid Application)

Download 7200.pdf

2399

2399 Form (Application for Home Care Services such as PASSPORT, Ohio Home Care Waiver, Choices, and Mental Retardation Waiver Services)-You can the complete the 2399 form and fax it to your local Department of Jobs and Family Services (DJFS). To find your local DJFS, go to DJFS

Download Form_-_2399.pdf

Sample PAS Results Page

Download Sample_PAS_Result_Page.pdf

Sample PAS and LOC Results Page

Download Sample_PAS___LOC_result_page.pdf

Most Used Scenarios

Most Common PASRR Scenarios Left click on this one.

Hospital Cover Sheet For Submission to Preadmission Review

Download Hospital cover sheet II.pdf

Nursing Home Fax Cover Sheet For Submission to Preadmission Review

Download NH Cover sheet.pdf

Transfer Form

Download scan0001.pdf

Hospital Transfer Form

Download Transfer Form.pdf

LTCC Worksheet

This worksheet can be used when submitting a request for a Non Medicaid admission to a Medicaid certified NF. It can also be used when reporting an expired convalescent stay.

Download ltcc worksheet.pdf

Bed Hold Schedule

Download Bed hold schedule.PDF

Physician Certification Page

Download Physician certification page.pdf

Additional Data Elements

Download Additional Data Elements Page.pdf

Additional Data Elements Page II

Download ADE page II.pdf

PACE (Program of all Inclusive Care) Referral Form

Download Pace Referral Form.pdf

Statement of Expert Evaluation

Download Statement of Expert Evaluation.pdf

Durable Power of Attorney for Health Care

Download Durable Power of Attorney for Health Care.pdf

Ohio Living Will

Download Living Will.pdf

QMB brochure

Download QMB brochure.pdf

Application For Help With Medicare Expenses (QMB)

Download application for help with medicare expenses.pdf

Worksheet to request PASSPORT Services, Level of Care for Nursing Home Placement or Assisted Living Waiver. You can fax it to your local PASSPORT site

Download INTAKE Fax Sheet.doc

JFS 6653-Medical Claim Review Request Form

Download 6653.pdf

Comprehensive Checklist for Nursing Home Visit

Download checklist.pdf

MDS (Minimum Data Set) Information

MDS Information

Ohio's Proposal for Money Follows the Person

Download mfp_grant_summary.pdf

ICF/MR Facilities in Ohio

Download Licensed-Facilities-index[1].pdf

ODMH mailed this letter to NF's 3/25/08. It is meant to involve guardians in the PAS process

Download Guardian involvement with PAS.pdf

Medicaid Citizen Requirements for U.S. Citizens

Download Medicaid requirement for U.S. Citizens.pdf

Retroactive Medicaid Coverage Application

Download retroactive medicaid coverage application.pdf

Minimum Income Allowance (MIA) worksheet for Nursing Home Resident and Spouse

Download Minumum monthly allowance.pdf

Brochure for Ohio Food Stamp program

Download Ohio food stamp program.pdf

Medicaid and Nursing Homes: A Planning Technique

Download Medicaid and Nursing Homes.pdf

Information on transfer of resources with regard to Medicaid

Download transfer of resources.pdf

Verification Checklist when applying for Medicaid

Download verificatin checklist.pdf

This is a great brochure on long term care programs in Ohio

Download long term care brochure.pdf

Information on estate recovery

Download estate recovery.pdf

Medicaid Spendown Information

Download Medicaid Spendown.pdf

Medicaid Institution Budget Worksheet

Download Medicaid Institutional Budget Worksheet.pdf

Patient Liability

Download Patient Liability.pdf

Certification of Need for Glucometer and Blood Glucose Supplies

Download blood glucose.pdf

Certification of Medical Necessity/Prescription for Oxygen Services

Download Oxygen supplies.pdf

Instructions for Completion of Home Care Certification Form (7137)

Download Instructions for Completion of Home Care Certification Form.pdf

Home Care Certification Form (7137)

Download Home Care Certification Form (7137).pdf

Certification of Medical Necessity for use of Ambulette

Download Ambulette.pdf

Certification of Medical Necessity for Ambulance

Download Ambulance.pdf

Fax sheet for PASSPORT, Assisted Living and other

Download fax worksheet.pdf

OAPLP Membership

Download OAPLP Membership.pdf

New ODMH Update

Download New ODMH Information.pdf

Aging Network Highlights

Download Some Aging Network Higlights or Lowlights from 2010.pdf

Medicare and Leaving the NF

Download Medicare.pdf

Enhanced Community Living

Enhanced Community Living

Description of book

Download Description of Book.pdf

Advertising for Professionals

Download Advertisement for Professionals.pdf

Advertising for Facilities

Download Advertisement for Facilities.pdf

Advertisement for Home Care

Download Advertisement for Home Care II.pdf

Headlines

Download headlines.pdf

Ohio Home Care Waiver

Download Ohio Home Care Waiver.pdf

Health Care Care Law Benefits Seniors

Download Health Care Law Benefits for Seniors.pdf

Home First

Download Home First.pdf

Home Choice Bulletin

Home Choice bulletin

Homestead

Download Homestead.pdf

483.12

Download 483.12.pdf

Advertisement for Facilities on Directory Page

Download Advertisement for Facilities.pdf

Ask Dan Sponsorship

Download Ask Dan Sponsor.pdf

PASRR/LOC Most Common Scenarios

Download scan0002.pdf

Ohio Hospitals with Psychiatric Units

Download Ohio Hospitals with Psychiatric Units.pdf

coordination between Medicaid Home Health Service with PASSPORT services

Download Coordination between Medicaid Home Health Service with PASSPORT services.pdf

Home Health Services Provisions and Requirements

Download 5101 3 12 01.pdf

Assisted Living Waiver:State Funded Option- Frequently Asked Questions

Download ALW State Funded Prog Option FAQ.pdf

State Funded Assisted Living Waiver Fact Sheet

Download State Funded ALW Fact Sheet-1.pdf

Enrollment Agreement for State Funded Assisted Living Waiver

Download Enrollment Agreement ODA 1116.pdf

Medicaid Eligibility Information for Assisted Living Waiver

Download Chapter 4 Section 4-6.pdf

ODMH Licensed Hospital Psychiatric Units and ODMH State Run Hospitals

Download Copy of Copy of PsychiatricHospitalsLicensedbyODMH.xls

Ohio's Medicaid Savings Plan

Download Ohio's Medicaid Savings Solutions.pdf

Single Waiver

Download Single Waiver.pdf

Single Waiver

Download Single Waiver December 17, 2011.pdf

Advertisement for Hospice

Download Advertisement for Hospice.pdf

Straw Man, Health Home and Single Waiver

Download Strawman, Health Home and Single Waiver.pdf

Health Home

Download Health Home.pdf

Quarterly Nursing Home Report

Download Nursing Home Quality Measures.pdf

Recent News

Download Recent News.pdf

New LOC Rules

Download LOC information.pdf

Waiver Benefit Package

Application for Advertisement

Download Advertisement for Northeast Ohio Senior Services Directory.pdf

ICDS Implementation

Download Integrated Care Delivery System- Started April 1, 2013.pdf

Fax Worksheet

Download fax worksheet.pdf

PASRR Changes for 7000

Download PASRR Changes regarding use of the 7000.pdf

PASRR Draft Rules

Download Draft for New PAS Requirements.pdf

LOC Q&A

Download LOC Q&A.pdf

PASRR & LOC Most Used Scenarios

Download PASRR & LOC Most Used Scenarios.pdf

Brochure/Registration for HOME Choice

Download Brochure and Registration for HOME Choice Training.pdf

Brochure/Registration for Assisted Living Waiver

Download Brochure and registration for Assisted Living Waiver Program.pdf

Private Psychiatric Hospitals in Ohio

Download Directory of Psychiatric Hospitals in Ohio.pdf

HENS/PASRR

Download HENS_PASRR instructions for testers.pdf

October 11-December 13, 2014 PASRR/LOC Training

Download Brochure and registration for October 11-December 13, 2014 PASRR and LOC training.pdf

Advertisement

Download Advertisement for www.longtermcareohio.pdf

Ohio Department of Job and Family Services APPLICATION FOR HELP WITH MEDICARE EXPENSES

QMB

Home Choice Application

Download Home Choice Application.pdf

Application for Long Term Care Directory

Download Application for Advertisment for Ohio Long Term Care Directory.pdf

Brochure and Registration for April 24-June 26, 2015 PASRR/LOC Training

Download Brochure and registration for April 24 - June 26, 2015 PASRR and LOC Training.pdf

October 10 -December 12, 2015 PASRR/LOC Training

Download Brochure and registration for October 10, 2015-December 12, 2015 PASRR and LOC Training.pdf

Explanation of PASRR/LOC self study

Download Explanation of self study PASRR and LOC Training.pdf

PASRR/LOC Training

Download Brochure and registration for October 8th -December 10th  PASRR and LOC Training.pdf

Brochure and Registration for March 4 to May 6, 2017 PASRR/LOC Training

Download Brochure and Registration for March 4 - May 6, 2017 PASRR and LOC Training.pdf

Brochure and Registration for April 22 to June 24, 2017 PASRR/LOC Training

Download Brochure and Registration for April 22 to June 24, 2017 PASRR and LOC Training.pdf