Ohio Department of Job and Family Services
RETROACTIVE MEDICAID WORKSHEET
This form is not an application, but is used to gather information used to determine whether you were eligible for
Medicaid in the three months before your application.
First Name
MI
Last Name
Medicaid billing # or SSN
Street Address, including Apt. #
City
Zip
County
If you have moved during the last 3 months, please give your last address
For the last three months, have you lived with the same people who are named in your application? Yes No
If not, please list:
People who lived with you, not listed in application People in the application who didn't live with you before
Name Relationship to you Age Name Relationship to you Age
In the last three months, have your income or resources changed?
Month Change to What changed?
Income
Resources
Income
Resources
Income
Resources
Please tell us about medical care your family received during the last three months.
Who was examined or treated?
Medical provider
(Who provided the care?)
Date of Treatment
or Exam
JFS 07110 (Rev. 9/2009)
