Type of request: Initial, Recertification (form due 14 to 30 days before expiration of existing Prior Authorization), Change or Increase, with the reason indicated.
Medicaid number: 12 digits.
Provider number: the Ohio Medicaid Provider Number is 7 digits.
Physician: the Ordering Physician's NPI Number is required.
Signature: Consumer/Authorized Representative's signature and date.
Certification: the individual submitting this form certifies that the information provided is true, accurate, and complete.
| Question | Answer |
|---|---|
| Form Name | ODM02374 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 32 |
| Avg. time to fill out | 6 min |
| Edition | Rev 9/2026 |
| Issuing agency | Ohio Department of Medicaid |
| Other names | ODM02374, ODM 02374, Ohio ODM 02374, PDN service request, Private Duty Nursing Service Request |
| Official source | ODM02374 (Rev 9/2026), Ohio Department of Medicaid |
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