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Ohio Department of Medicaid QUALIFIED INCOME TRUST BANK VERIFICATION INDIVIDUAL INFORMATION Individual Name (Last, First, MI) Date of Birth (mm/dd/YYY) Medicaid ID # (12 digits) Case Number Individual
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What is odm 10193 form?
The ODM 10193 form is a document used for reporting certain information to the Ohio Department of Medicaid.
Who is required to file odm 10193 form?
Providers and facilities that have received payments from the Ohio Medicaid program are required to file the ODM 10193 form.
How to fill out odm 10193 form?
The ODM 10193 form can be filled out online or by downloading a PDF version from the Ohio Department of Medicaid website. Providers and facilities must provide accurate and up-to-date information on the form.
What is the purpose of odm 10193 form?
The purpose of the ODM 10193 form is to collect and report data related to Medicaid payments and services provided by providers and facilities.
What information must be reported on odm 10193 form?
Information such as provider or facility name, Medicaid ID number, services provided, payment amount, and dates of service must be reported on the ODM 10193 form.
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