JFS 02399 (Rev. 1/2012)
Ohio Department of Job and Family Services
REQUEST FOR MEDICAID HOME AND COMMUNITY-BASED SERVICES (HCBS)
You must receive Medicaid to receive waiver services. If you have not applied for Medicaid or you
have applied in the past but been denied, you must apply at this time.
Section I: To be completed by the individual or HCBS referring agency:
City, State and Zip Code
Name of authorized representative (Last, First, MI)
Phone Number
Address of authorized representative (Apartment #)
City, State and Zip Code of authorized representative
Indicate applicable waiver(s) below (check all that apply):
Ohio Department of Job and Family Services
Ohio Home Care Waiver
Other
Ohio Department of Developmental Disabilities (specify waiver):
Individual Options Waiver
Self Empowerment Life Funding (SELF) Waiver
Level One Waiver
Other
Ohio Department of Aging (specify waiver):
PASSPORT Waiver
CHOICES Waiver
Assisted Living Waiver
Other (specify):
I authorize the County Department of Job and Family Services (CDJFS) and its designees to explore my
eligibility for Medicaid coverage of HCBS waiver services.
Signature of Individual requesting medical assistance (or Authorized Representative)
Name of Person who helped complete this form (please
print)
Signature of Person who helped complete this
form
Date
Section II: To be completed by the CDJFS:
Name of CDJFS Case Worker (please print)
Is the individual currently on Medicaid
or is an application for Medical
A
s
sistance pending?
Yes No
If yes
CRIS-E Number:
Application Date:
Signature of CDJFS Case Worker
Date Received By CDJFS
