Social Security Card

In accordance with OAC 5101:3-46-04 “Ohio home care waiver: definitions of the covered services and provider requirements and specifications,” applicants must present their Social Security number card to be copied and included with the application packet. The Social Security number must be compared to and confirmed to match the Social Security number entered elsewhere on the application and other accompanying documents, such as the background check. The application must not be processed if discrepancies with the Social Security number are identified. The Office of Medical Assistance must be alerted if discrepancies appear to be an applicant’s attempt to present false or misleading information.

Identification/Government-Issued Identification

Individual applicants must provide a current, valid form of identification, which may include an alien identification card, a valid State of Ohio identification card, a valid driver’s license, or other government-issued photo identification. The identification item must be clearly photocopied and included with the application.

National Provider Identifier

The Health Insurance Portability and Accountability Act of 1996 require providers to have a National Provider Identifier so there is a standard unique identifier for health care providers. Registered Nurses and Licensed Practical Nurses and home health agencies are required to obtain a National Provider Identifier.

Non-agency personal care aides, supplemental transportation services, home delivered meal and home modification providers are exempt from having a National Provider Identifier.

In addition to completing the National Provider Identifier portion of the application, applicants must attach a copy of the notice from the National Provider Identifier Enumerator to verify the National Provider Identifier number.

W-9 Request for Taxpayer Identification Number and Certification

Individual applicants must complete and submit a W-9 form that contains their name, address, Social Security number, original signature and date. Individual applicants may not use a group tax identification number. The Social Security number entered on the W-9 must match the Social Security number entered elsewhere on the application and must match the Social Security number on the Social Security card provided by the applicant.

 

Agency/organization applicants must also complete and submit a signed W-9 form. The W-9 should contain the proprietor’s Social Security number and/or the Employer Identification Number. Only page one of the W-9 form needs to be included as a part of the application.

Signed Medicaid Provider Agreement

The Provider Oversight Contractor must have an original signature as a part of the enrollment process. Therefore, the applicant must print out, sign and upload a copy of the provider-signed agreement.