Form Jfs 06777 PDF Details

Form Jfs 0677 is a document that you will need to complete in order to apply for food stamps in the state of Ohio. The form can be daunting, but our guide will take you through each section and help you understand what is required. Keep in mind that the requirements for food stamps vary from state to state, so be sure to check with your local department of social services if you have any questions. Completing Form Jfs 0677 may seem like a daunting task, but with our guide by your side, you'll be able to fill it out quickly and easily. Keep in mind that the requirements for food stamps vary from state to state, so be sure to check with your local department of social services if you have any questions. Thanks for reading!

QuestionAnswer
Form NameForm Jfs 06777
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesgroupinfo ohio job family services form

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Ohio Department of Job and Family Services

GROUP PRACTICE PROVIDER INFORMATION

To add individual practitioners to your group, please complete and return this form to the address shown below.

JFS 06777 (4/2002)

State Use Only

Group Name

Street Address

City, State and Zip Code

Group Provider Number

Date

List individual practitioners participating in your group. If additional space is required, use back of this form.

Individual Name (print or type)

Address

Individual Ohio Medicaid 7-digit Provider Number

The Group Provider so named above does certify and agree to the following:

1.Written authorization or a contractual agreement between each individual practitioner and the group entity (employer, facility, health care delivery system, etc.) is on file permitting the group provider, so named above, to submit charges to the Ohio Department of Job and Family Services and receive payments on behalf of the individual attending practitioner for services rendered to Ohio Medicaid recipients as a part of the group activity.

2.Notification will be provided to the Ohio Department of Job and Family Services of the addition of any practitioner(s) to the group entity or the deletion of any individual practitioner(s) from the entity so named above.

Signature of Authorized Agent

Printed name and title

Date

Return to: Ohio Department of Job and Family Services, Provider Enrollment Unit, P.O. Box 1461, Columbus, Ohio 43216-1461.

JFS 06777 (4/2002)