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ACTION: Originate: 07/17/2017 5:00 Rule Summary and Fiscal Analysis (Part A) Ohio Department of Medicaid Agency NameTommi Potter DivisionContact50 West Town Street Suite 400 Columbus OH 43218270961475238776149951301Agency
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The 5160-56-04 new is a form used for reporting specific information related to healthcare services and claims, typically required by certain government agencies or insurance providers.
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To fill out the 5160-56-04 new, follow the instructions provided on the form, ensuring all required fields are completed accurately, including patient information, service details, and provider information.
The purpose of the 5160-56-04 new is to collect data necessary for the evaluation of healthcare services and to ensure compliance with federal and state regulations.
Information that must be reported includes patient demographics, service dates, types of services provided, billing details, and provider identifiers.
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