Form ODM07236 "Your Rights & Responsibilities as a Consumer of Medicaid Health Coverage" - Ohio

Form ODM07236 is a Ohio Department of Medicaid form also known as the "Your Rights & Responsibilities As A Consumer Of Medicaid Health Coverage". The latest edition of the form was released in July 1, 2014 and is available for digital filing.

Download a PDF version of the Form ODM07236 down below or find it on Ohio Department of Medicaid Forms website.

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Download Form ODM07236 "Your Rights & Responsibilities as a Consumer of Medicaid Health Coverage" - Ohio

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YOUR RIGHTS & RESPONSIBILITIES AS A CONSUMER OF MEDICAID HEALTH COVERAGE
The Ohio Department Medicaid (ODM) assures that no person seeking participation in any program or person
currently participating in a program shall have services denied/delayed or otherwise be discriminated against
on the basis of race, color, religion, sex, national origin, disability, age, veteran status or sexual orientation.
YOU HAVE A RIGHT TO A STATE HEARING before the ODJFS if you are not satisfi ed with actions taken or
decisions on your application. When the county department of job & family services receives your application, you will get a
form that tells you how to ask for a hearing.
YOU HAVE A RESPONSIBILITY:
TO REPORT CORRECT AND UPDATED INFORMATION. You are always responsible for giving complete and
correct information about yourself and members of your household. You must include all supporting documentation
and verifi cations with your completed application. You must report to the county department of job & family services,
within 10 days, any change in your circumstances, such as: •You move to another address •Someone moves in with
you or moves out •Any household member’s income changes • A household member gets or loses a job •A child
drops out of school or reaches the age of 19 •The end of your pregnancy and/or the birth of your child(ren).You
should also report if anyone in your household, (including children) becomes disabled, is unable to work, or has
applied for disability benefi ts (e.g., Social Security Disability, SSI, Workers Compensation, veteran’s benefi ts.) You
should report this information as soon as you become aware of it because it may help the person stay eligible for
Medicaid benefi ts.
TO PROVIDE PROOF OF U.S CITIZENSHIP/ALIEN STATUS. If you or members of your family are applying for
Healthy Start, Healthy Families (Medicaid), you must provide the county department of job & family services with
verifi cation of U.S. citizenship for each person you are applying for. Family members who are not U.S. citizens must
provide the county department of job & family services with proof of alien status such as an alien registration card or
re-entry permit. If you are applying for Healthy Start (Medicaid) for a child, but not for yourself, you are not required
to give proof of your own citizenship.
TO COOPERATE WITH ESTABLISHING PATERNITY AND THIRD PARTY MEDICAL SUPPORT. You must
agree to help establish paternity (who the legal father is) for each child who gets assistance from Medicaid, and you
must include medical support payments in the child support order.
TO GIVE MEDICAID ANY PAYMENTS YOU RECEIVE FROM OTHER HEALTH INSURANCE. You must tell the
county department of job & family services about any other medical coverage you have or if someone else is legally
responsible for paying medical bills for you or members of your family. Medicaid does not pay medical bills that a
private health insurance company is supposed to pay. When you accept assistance from Medicaid, you must agree to
give the ODM your right to medical payments from a private medical insurance company while you have Medicaid.
If you receive money directly from your medical insurance company to cover medical bills that Medicaid has paid for
you or for anyone for whom you are legally responsible for, the ODM has the right to get that money back from you.
TO COOPERATE WITH QUALITY CONTROL REVIEWS. Your name may be picked from a list of all the eligible
cases in Ohio to see if you really are eligible for assistance based on the information you gave the ODM. If your case
is picked, you must cooperate by answering all the questions in order to continue to get medical coverage.
RELEASE OF INFORMATION ON SOCIAL SECURITY NUMBER FOR MEDICAID. You must give the county
department of job & family services your Social Security Number (SSN) or apply for a SSN for each person seeking
medical coverage. If you are applying for Medicaid for a child, you are not required to provide your own SSN, but
we must have the child’s SSN in order for the child to receive Medicaid. If you are applying for Medicaid for yourself,
you must provide your SSN. The agency will use the SSN to verify income, eligibility, and the amount of medical
assistance payments we will make on your behalf. Your SSN may also be matched with the records in other agencies
such as the Social Security Administration. These matches may be done by computer or on an individual basis. Your
social security number is given to medical insurance companies to see if there is coverage to pay all or part of your
medical bills. Your social security number will be used during program reviews to make sure you are eligible for this
program.
SIGNATURES:
I received a copy of and I have read all my rights and responsibilities or they have been read to me, and I understand them.
Applicant
Date
Authorized Representative or Person Helped Complete the Form
Date
If an “X” is used, Signature of One Witness is Needed
Date
ODM 07236 (7/2014)
Formerly JFS 07236
Reset Form
YOUR RIGHTS & RESPONSIBILITIES AS A CONSUMER OF MEDICAID HEALTH COVERAGE
The Ohio Department Medicaid (ODM) assures that no person seeking participation in any program or person
currently participating in a program shall have services denied/delayed or otherwise be discriminated against
on the basis of race, color, religion, sex, national origin, disability, age, veteran status or sexual orientation.
YOU HAVE A RIGHT TO A STATE HEARING before the ODJFS if you are not satisfi ed with actions taken or
decisions on your application. When the county department of job & family services receives your application, you will get a
form that tells you how to ask for a hearing.
YOU HAVE A RESPONSIBILITY:
TO REPORT CORRECT AND UPDATED INFORMATION. You are always responsible for giving complete and
correct information about yourself and members of your household. You must include all supporting documentation
and verifi cations with your completed application. You must report to the county department of job & family services,
within 10 days, any change in your circumstances, such as: •You move to another address •Someone moves in with
you or moves out •Any household member’s income changes • A household member gets or loses a job •A child
drops out of school or reaches the age of 19 •The end of your pregnancy and/or the birth of your child(ren).You
should also report if anyone in your household, (including children) becomes disabled, is unable to work, or has
applied for disability benefi ts (e.g., Social Security Disability, SSI, Workers Compensation, veteran’s benefi ts.) You
should report this information as soon as you become aware of it because it may help the person stay eligible for
Medicaid benefi ts.
TO PROVIDE PROOF OF U.S CITIZENSHIP/ALIEN STATUS. If you or members of your family are applying for
Healthy Start, Healthy Families (Medicaid), you must provide the county department of job & family services with
verifi cation of U.S. citizenship for each person you are applying for. Family members who are not U.S. citizens must
provide the county department of job & family services with proof of alien status such as an alien registration card or
re-entry permit. If you are applying for Healthy Start (Medicaid) for a child, but not for yourself, you are not required
to give proof of your own citizenship.
TO COOPERATE WITH ESTABLISHING PATERNITY AND THIRD PARTY MEDICAL SUPPORT. You must
agree to help establish paternity (who the legal father is) for each child who gets assistance from Medicaid, and you
must include medical support payments in the child support order.
TO GIVE MEDICAID ANY PAYMENTS YOU RECEIVE FROM OTHER HEALTH INSURANCE. You must tell the
county department of job & family services about any other medical coverage you have or if someone else is legally
responsible for paying medical bills for you or members of your family. Medicaid does not pay medical bills that a
private health insurance company is supposed to pay. When you accept assistance from Medicaid, you must agree to
give the ODM your right to medical payments from a private medical insurance company while you have Medicaid.
If you receive money directly from your medical insurance company to cover medical bills that Medicaid has paid for
you or for anyone for whom you are legally responsible for, the ODM has the right to get that money back from you.
TO COOPERATE WITH QUALITY CONTROL REVIEWS. Your name may be picked from a list of all the eligible
cases in Ohio to see if you really are eligible for assistance based on the information you gave the ODM. If your case
is picked, you must cooperate by answering all the questions in order to continue to get medical coverage.
RELEASE OF INFORMATION ON SOCIAL SECURITY NUMBER FOR MEDICAID. You must give the county
department of job & family services your Social Security Number (SSN) or apply for a SSN for each person seeking
medical coverage. If you are applying for Medicaid for a child, you are not required to provide your own SSN, but
we must have the child’s SSN in order for the child to receive Medicaid. If you are applying for Medicaid for yourself,
you must provide your SSN. The agency will use the SSN to verify income, eligibility, and the amount of medical
assistance payments we will make on your behalf. Your SSN may also be matched with the records in other agencies
such as the Social Security Administration. These matches may be done by computer or on an individual basis. Your
social security number is given to medical insurance companies to see if there is coverage to pay all or part of your
medical bills. Your social security number will be used during program reviews to make sure you are eligible for this
program.
SIGNATURES:
I received a copy of and I have read all my rights and responsibilities or they have been read to me, and I understand them.
Applicant
Date
Authorized Representative or Person Helped Complete the Form
Date
If an “X” is used, Signature of One Witness is Needed
Date
ODM 07236 (7/2014)
Formerly JFS 07236
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