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Forms

MyCare Provider CD form

Joint Electronic Funds Transfer and Electronic Remittance Advice Signup

Community Behavioral Health Authorization Form

Waiver of Liability (WOL) Form

CMS 1500 Form

Prior Authorization Form (see attached Prior Authorization List)

BH Prior Authorization Form

Provider Pharmacy Coverage Determination Form

Par Provider Dispute Form

Non-Par Provider Appeal Form

Ohio Department of Job and Family Services (ODJFS) Forms Central

Nursing Facility Request Form