Form ODM10198 "Addendum to Odm Provider Agreement Nursing Facility Ventilator Program" - Ohio

Form ODM10198 or the "Addendum To Odm Provider Agreement Nursing Facility Ventilator Program" is a form issued by the Ohio Department of Medicaid.

The form was last revised in December 1, 2018 and is available for digital filing. Download an up-to-date Form ODM10198 in PDF-format down below or look it up on the Ohio Department of Medicaid Forms website.

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Download Form ODM10198 "Addendum to Odm Provider Agreement Nursing Facility Ventilator Program" - Ohio

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Ohio Department of Medicaid
ADDENDUM TO ODM PROVIDER AGREEMENT NURSING FACILITY VENTILATOR PROGRAM
SECTION I: PROVIDER INFORMATION
Facility Name:
(DBA)
Facility Street Address:
City:
State:
Zip Code:
Medicaid Provider Number:
Room/Bed Numbers in Vent Unit:
SECTION II: ADDITIONAL PROVIDER REQUIREMENTS
In addition to the requirements specified in the Nursing Facility Provider Agreement, the Nursing Facility (NF) shall comply with all
of the requirements included in Ohio Administrative Code 5160-3-18 Nursing Facilities (NFs): Ventilator Program. The facility must
also comply with Paragraph (E) Ventilator weaning if they are authorized to provide ventilator weaning services under this
program as designated below.
SECTION III: PROVIDER SIGNATURE
(OPTION A) By my signature below, I certify that I am the owner, officer, chief executive officer, general partner, or board
member of the business organization entering into this provider agreement to operate this ventilator services unit under the
Medicaid program. I agree to be bound by this agreement and all applicable laws. I certify the information submitted on the
request and the information as it appears on this provider agreement is accurate and complete. I agree that our business
organization will notify the Ohio Department of Medicaid in writing of any subsequent changes to the information contained in
the request or in this agreement.
Provider Representative Name
Title
(print or type)
(print or type)
Provider Representative Signature
Date
(OPTION B) By my signature below, I certify that I am signing with agent authority from and on behalf of,
Name
Title
(print or type) _______________________________________________
(print or type) __________________________________
who is the owner, officer, chief executive officer, general partner, or board member of the business organization entering into this
provider agreement to operate this ventilator services unit in the Medicaid program, and that I have been given the authority to
bind the business organization to this agreement and all applicable laws. I certify on the organization’s behalf that the information
submitted on the request and the information as it appears in this provider agreement is accurate and complete. Further, by my
signature, I am binding the business organization to notify the Ohio Department of Medicaid in writing of any subsequent changes
to the information contained in the request or in this agreement.
Name of Authorized Agent for Provider
Title
(print or type)
(print or type)
Authorized Agent Signature
Date
SECTION IV: AUTHORIZATION GRANTED BY ODM
Effective Date
Approval
Basic Ventilator Services Only
Basic Ventilator Services and Ventilator Weaning Services
SECTION V: SIGNATURE OF AUTHORIZED DEPARTMENT OF MEDICAID (ODM) REPRESENTATIVE
Name of Authorized ODM Representative
Title
(print or type)
(print or type)
Signature
Date
ODM 10198 (Rev. 12/2018)
Ohio Department of Medicaid
ADDENDUM TO ODM PROVIDER AGREEMENT NURSING FACILITY VENTILATOR PROGRAM
SECTION I: PROVIDER INFORMATION
Facility Name:
(DBA)
Facility Street Address:
City:
State:
Zip Code:
Medicaid Provider Number:
Room/Bed Numbers in Vent Unit:
SECTION II: ADDITIONAL PROVIDER REQUIREMENTS
In addition to the requirements specified in the Nursing Facility Provider Agreement, the Nursing Facility (NF) shall comply with all
of the requirements included in Ohio Administrative Code 5160-3-18 Nursing Facilities (NFs): Ventilator Program. The facility must
also comply with Paragraph (E) Ventilator weaning if they are authorized to provide ventilator weaning services under this
program as designated below.
SECTION III: PROVIDER SIGNATURE
(OPTION A) By my signature below, I certify that I am the owner, officer, chief executive officer, general partner, or board
member of the business organization entering into this provider agreement to operate this ventilator services unit under the
Medicaid program. I agree to be bound by this agreement and all applicable laws. I certify the information submitted on the
request and the information as it appears on this provider agreement is accurate and complete. I agree that our business
organization will notify the Ohio Department of Medicaid in writing of any subsequent changes to the information contained in
the request or in this agreement.
Provider Representative Name
Title
(print or type)
(print or type)
Provider Representative Signature
Date
(OPTION B) By my signature below, I certify that I am signing with agent authority from and on behalf of,
Name
Title
(print or type) _______________________________________________
(print or type) __________________________________
who is the owner, officer, chief executive officer, general partner, or board member of the business organization entering into this
provider agreement to operate this ventilator services unit in the Medicaid program, and that I have been given the authority to
bind the business organization to this agreement and all applicable laws. I certify on the organization’s behalf that the information
submitted on the request and the information as it appears in this provider agreement is accurate and complete. Further, by my
signature, I am binding the business organization to notify the Ohio Department of Medicaid in writing of any subsequent changes
to the information contained in the request or in this agreement.
Name of Authorized Agent for Provider
Title
(print or type)
(print or type)
Authorized Agent Signature
Date
SECTION IV: AUTHORIZATION GRANTED BY ODM
Effective Date
Approval
Basic Ventilator Services Only
Basic Ventilator Services and Ventilator Weaning Services
SECTION V: SIGNATURE OF AUTHORIZED DEPARTMENT OF MEDICAID (ODM) REPRESENTATIVE
Name of Authorized ODM Representative
Title
(print or type)
(print or type)
Signature
Date
ODM 10198 (Rev. 12/2018)
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