Forms, Billing and Reference Guides

• 2017 Quick Reference Guide for Ohio Participating Care Providers
• 2017 Quick Reference Guide for Ohio Non-Participating Care Providers
• Balance Billing Reminder for UnitedHealthcare Dual Complete
• EPSDT Billing Notice
• Healthchek EPSDT Coding Guide

Use these forms for appointments related to Early Periodic Screening, Diagnosis, and Treatment / Healthchek.

• Newborn EPSDT / Healthchek Form
• 4 weeks EPSDT / Healthchek Form
• 2 months EPSDT / Healthchek Form
• 4 months EPSDT / Healthchek Form
• 6 months EPSDT / Healthchek Form
• 9 months EPSDT / Healthchek Form
• 12 months EPSDT / Healthchek Form
• 15 months EPSDT / Healthchek Form
• 18 months EPSDT / Healthchek Form
• 24 months EPSDT / Healthchek Form
• 30 months EPSDT / Healthchek Form
• 3 years EPSDT / Healthchek Form
• 4 years EPSDT / Healthchek Form
• 5 years EPSDT / Healthchek Form
• 6-10 years EPSDT / Healthchek Form
• 11-14 years EPSDT / Healthchek Form
• 15-20 years EPSDT / Healthchek Form

• Case Rate Agreement Form 
• Coordination of Care Form 
• Obstetrical Needs Assessment Form 
• Sterilization Form 
• UnitedHealthcare Community Plan of Ohio Prior Authorization Form

The Ohio Department of Medicaid (ODM) ICD-10 team will post monthly ICD-10 TIPS which will offer clarification and guidance to ODM providers and ODM staff on the transition to the ICD-10 codes. The following links will take you to ODM resources concerning the ICD-10 transition.

• Ohio Department of Medicaid ICD-10 Website