Manual submission of this form requires authorization from the local PASSPORT Administrative Agency (PAA).
Required fields: The fields marked with an (*) are required.
Section C: Supporting documentation required. Choose only ONE option.
Time limit: Emergency NF stay in situations requiring protective services, 7 days. Respite NF stay, 14 days.
Dementia: If “Yes” or “Unknown”, please attach documentation related to symptoms, treatment, or a diagnosis of dementia.
Signature: This form must be signed and dated to be valid.
Incomplete forms: Incomplete forms may be returned with a request for further information.
| Question | Answer |
|---|---|
| Form Name | Form ODM 03622 |
| Form Length | 4 pages |
| Fillable? | Yes |
| Fillable fields | 137 |
| Avg. time to fill out | 23 min |
| Edition | 9/2021 |
| Issuing agency | Ohio Department of Medicaid |
| Who signs | The submitter |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | ODM 03622, ODM03622, ODM 3622, Form ODM 03622, Ohio PASRR, Preadmission Screening and Resident Review Identification Screen |
| Official source | Form ODM 03622 (Rev 9/2021), Ohio Department of Medicaid |
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