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!
Question | Answer |
---|---|
Form Name | Form Jfs 06777 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | groupinfo ohio job family services form |
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
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
JFS 06777 (4/2002)