Forms and Instructions regarding Form Completion
Contact information changes:
Changing information such as address, telephone number, etc. Note: Do not check either MBE or EDGE on the vendor forms, as this is not applicable. Providers using a tax ID number, rather than a social security number, must send a letter notifying DODD of changes. The letter must be on company letterhead and must be sent in addition to the OBM Vendor Information Change Form.
Required forms: OBM vendor information change form
Also, the provider will need to update their contact information in the Provider Certification System. If they have not already done so, they will need to fill out a security affidavit and indicate that they wish to have access to “PCU user”. Instructions for Provider Certification User Self Update [PCU]
[See below under “to request access to billing systems”]
Name changes:
Required forms: OBM vendor information change form
In the case of a marriage/divorce, a copy of the marriage license, divorce paperwork or driver’s license is also necessary.
Direct deposit:
[To start or end direct deposit, or to change account information]
Required form: Direct deposit form
Forward the signed authorization form along with a voided check orsavings deposit slip to:
Ohio Shared Services
4310 E. Fifth Ave.
Columbus, OH 43219
To associate/disassociate with a billing agent:
[To start or stop using a billing agent]
Required forms: Provider request for association with a billing agent
To request access to billing systems:
Required forms: Security affidavit
For further information: Information for new and existing providers
To bill for environmental modifications:
Required forms: Form 2
Security affidavits are sent to:
Security Coordinator
Fax: (614) 752 - 4673
Or mailed to:
Security Coordinator
Division of Information Systems
30 E Broad St, 12th Floor
Columbus, OH 43215
All other forms are sent to:
FISCAL ADMINISTRATION
OHIO DEPARTMENT OF DODD
30 E BROAD ST 13TH FL
COLUMBUS OH 43215-3434
Or fax to: (614) 466-7359