01/11/2019

Standard Authorization Form now available on ODM website

Standard Authorization Form Now Available on ODM Website

There is now a Standard Authorization Form (Form Number: ODM 10221) available, designed to improve patient care across multiple providers by making it easier to share protected health information in a secure manner. The form is applicable to all covered entities in Ohio.

It is not required to be used, however, a properly executed form must be accepted by the receiving entity. The requirement to accept a properly executed form is applicable within 30 days of Jan. 3, 2019.

• Standard Authorization Form
• Instructions for Completing Standard Authorization Form
• Additional details about the Standard Authorization Form are available in the fact sheet
• Questions about the Standard Authorization Form may be directed to StandardAuthForm@medicaid.ohio.gov
• Introductory video on the Standard Authorization Form
• Instructional video on the Standard Authorization Form

The form is available on the Ohio Department of Medicaid website under the Provider Tab.