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Ohio Department of Medicaid | 50 West Town Street, Suite 400, Columbus, Ohio 43215. Consumer Hotline: 800-324-8680 | Provider Integrated Helpdesk: 800-686-1516
pursuant to this authorization may include information concerning testing, diagnosis or treatment of HIV/AIDS, psychiatric and/or drug/alcohol treatment, and/or sexual assault. FORM A – AUTHORIZATION FOR RELEASE OF INFORMATION FROM COVERED ENTITIES (OTHER THAN PART 2 PROGRAMS)
• The standard form is authorized under section 3798.10 of the Ohio Revised Code and promulgated under rule 5160-1-32.1 of the Ohio Administrative Code, Standard Authorization Form. • The form is applicable to all covered entities in Ohio, and is not required to be used, but a properly executed form must be accepted by the receiving entity.
Ohio Department of Medicaid | 50 West Town Street, Suite 400, Columbus, Ohio 43215 Consumer Hotline: 800-324-8680 | Provider Integrated Helpdesk: 800-686-1516 Powered by
Ohio Medicaid Authorization Form – Community Behavioral Health The Ohio Managed Care and MyCare plans have developed a uniform prior authorization form for community BH services. Ohio Medicaid Authorization Form Updated January 24, 2023
This standard authorization form should be used by an individual or their personal representative to give consent to the release of personal health information. This form is not a patient access request under 45 CFR 164.524.
Only the prescribing provider or a member of the prescribing provider's staff may request prior authorization. Prescriber’s Signature (or staff of prescriber)
Myers and Stauffer (PPAC) - Ohio Medicaid Pharmacy; FFS Prior Authorization; Pharmacy Billing Information
Providers should be aware that a new form, Standard Authorization Form (Form Number: ODM 10221), is now available from the Ohio Department of Medicaid. The purpose of the form is to improve care coordination for a patient across multiple providers by making it easier to share protected health information in a secure manner.
Case Number/Medicaid ID The CDJFS, the Ohio Department of Medicaid (ODM) and ODM’s contracted designees (including Medicaid managed care plans) are authorized to disclose my protected health information (PHI) to my authorized representative designated in Section 1 of this form.