Oda 1105 Form – Fill Out and Use This PDF

ASSURANCES

These assurances are made by the undersigned provider to the Ohio Department of Aging. The Provider agrees to comply with these assurances, state statutes, Ohio Administrative Code rules and Federal statutes and rules, and agrees and certifies to:

1.Provide services as authorized by the case manager without regard to race, creed, color, age, sex, sexual orientation, national origin, source(s) of payment, handicap or disability.

2.Submit claims only for services actually provided and bill ODA for no more than the usual and customary fee charged other patients for the same service.

3.Ascertain and recoup all third-party resource(s) available to the consumer prior to billing ODA.

4.Accept the allowable reimbursement for all covered services as payment-in-full and will not seek reimbursement for that service from the consumer, any member of the family, or any other person.

5.Maintain all records necessary and in such form so as to fully disclose the extent of services provided and significant business transactions for a period of three years after the date of receipt of the payment based upon those records or until an audit is initiated within the three year period, until the audit is completed and every exception resolved, whichever is longer.

6.Furnish to ODA and/or its designee any information maintained under paragraph 5 above for audit or review purposes. Failure to supply requested records within thirty days may result in revocation of certification as a long term care service provider.

7.Inform ODA within thirty days of any changes in licensure, certification, ownership, control, operational management, address, business name, telephone number and/or federal tax identification number.

8.Immediately notify ODA in writing of any owner, director, officer, or operational manager who is subject to sanction under Medicare, Medicaid, or any Title XX program or service.

9.Immediately notify ODA in writing of any owner, director, officer or operational manager, employee or contractor who has been convicted of a criminal offense as outlined in 173.41 of the Revised Code.

10.Comply with the Conditions of Participation set forth in section 173-39-02 of the Administrative Code and the service specifications set forth in sections 173-39-02.1 through 173-39-02.18 of the Administrative Code.

11.Provide to ODA, through the court of jurisdiction, notice of any action brought by the provider in accordance with the Title 11 of the United States Code (Bankruptcy). Notice shall be mailed to Provider Certification, Ohio Department of Aging, 50 West Broad Street, Columbus, Ohio 43215.

12.Ensure no owner, officer, authorized agent, associate, manager or employee has been determined ineligible to be associated with a Medicaid program.

13.The authorized representative signing these assurances certifies that the information contained in these assurances and in the application for certification as a long term service provider is complete and true.

ODA 1105

Rev 8/15/08

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MEDICAID WAIVER PROVIDER ENROLLMENT

I am requesting enrollment as a Medicaid Provider for the following Home and Community-Based Services Waiver: PASSPORT Choices Assisted Living

I currently provide services for the following Waivers (if applicable):

TO BE COMPLETED BY STATE AGENCY:

ºAdd category of service to current Medicaid number.

ºAssign a new provider number and category of service. Attached is completed and signed Medicaid Provider Agreement.

The State Agency has certified this provider for the following waiver services in these counties at the following rates and recommends approval for enrollment:

Medicaid Provider Number Assigned:

ODA 1105

Rev 8/15/08

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