This form is to provide us information to bill / check benifits with Ohio Medicaid. If you do not know an answer to a question on the form below, please put a (?) in the answer box and we will follow up with you to help you find the answer. Please try to answer as many questions as possible to get your bed as soon as possible! If you have commercial insurance along with Medicaid please fill out a second form with your commercial insurance on it. A lot of times Medicaid will need a denial from your commercial insurance to pay your claim. We look forward to serving you and your family.