Home Choice Application Form Ohio Medicaid
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1Ohio Department of Medicaid
HOME CHOICE APPLICATION
Applicant Name (Last, First, MI)
Applicant Phone Number
Medicaid ID Number
(mm/dd/yyyy)
(12 digits)
Is the applicant on Medicaid?
Gender
Date of Birth
☐ Yes
☐ No
☐ M
☐ F
County
List any communication barriers
(mm/dd/yyyy)
Name of Facility
Date of Admission
Street Address
Facility Phone Number
City
State
Zip Code
Facility FAX Number
☐ Hospital
Type of Facility
☐ Qualified Residential Treatment Center (individual under the age of 22 only)
☐ Nursing Facility
☐ Psychiatric Hospital (individual under the of age 22 and over the age of 60 only)
☐ ICF-IID
Referral Source
☐ Self
☐ CIL
☐ Nursing Facility
☐ Family and Children First Council
☐ Friend
☐ CLS
☐ ICF-IID
☐ Other (specify):
☐ Family
☐ LTC Ombudsman
☐ Hospital
☐ Community Agency (specify):
☐ Physician
☐ County Board of DD
☐ PASRR
Name of person making referral
Person referring Phone Number
Referral Date (mm/dd/yyyy)
Does the applicant have income?
☐ No (specify)
:
☐ Yes
Does the applicant have a mental health diagnosis?
If yes to any
☐ No (specify):
diagnoses, is the
☐ Yes
applicant receiving
Does the applicant have a drug and/or alcohol diagnosis?
treatment or
☐ No (specify):
☐ Yes
services?
Does the applicant have a developmental disability diagnosis?
☐ Yes
☐ No (Specify)
☐ No
☐ Yes
Additional information that will assist in processing this application:
Who else might we contact about the person being referred?
Contact Phone Number
The following must be filled out if applicant has a legal guardian or is under the age of 18.
LEGAL GUARDIAN (if applicable)
Name (Last, First, MI)
Type of Guardianship
☐ Person
☐ Estate ☐ Person and Estate
Address
City
State
Zip Code
Phone Number
PARENT (if applicant is under the age of 18)
Name (Last, First, MI)
Address
City
State
Zip Code
Phone Number
(mm/dd/yyyy)
Signature of Applicant or Legal Guardian (REQUIRED)
Date
Submit completed form to:
Ohio Department of Medicaid/ Office of Operations
HOME Choice Operations Unit
Box 182709, 4
th
Floor
Columbus, Ohio 43218-2709
Email: HOME_Choice@medicaid.ohio.gov
Phone: (888) 221-1560
FAX: (614) 466-6945
ODM 02361 (Rev. 3/2017)
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