WebThe County Department of Job and Family Services (CDJFS), the Ohio Department of Medicaid (ODM) and ODM’s contracted designees (including Medicaid managed care plans)are authorized to disclose my protected health information (PHI) to my authorized representative designated in Section 1 of this form. WebFax your signed application to (513) 946-1076. (Applications can be faxed from any Public Library of Cincinnati and Hamilton County branch free of charge) Deliver in person. Signed applications can be scanned at the HCJFS kiosk in the lobby at HCJFS’s main location: 222 East Central Parkway. Cincinnati, OH 45202.

ODJFS - Hearing Decisions and Administrative Appeals

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ODJFS eManuals - Ohio

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