Personal Care Assistant Request Form

This form may be used when a Consumer is requesting personal care assistance and the person requested must first apply to become an OHC Provider.

This form contains important Consumer information in case of Consumer emergencies or change of status.

Consumer Needs Check List

This form indicates a Consumers needs and frequency assistance is required.

PCA Visit Note

This form provides a tool for aides to document visit and services provided.

Clinical Record

This form contains all pertinent Consumer information and is maintained by the Providers for all Consumers receiving services.

Discharge Summary

This form is completed when a Provider ends services or when a Consumer is discharged from the home to a hospital or care center.

Daily Time/ Unit & Task Sheet

This form serves as a record for the provider's time and services providerd.

Daily Narrative Note

This form serves as a seven day record for provider's daily notes.

Tax Payment Affidavit

Non-agency providers are required per Ohio Home Care rule to participate yearly in a structural review meeting with a provider monitor. The Tax Payment Affidavit is a required form that must be presented to the monitor at the review and verifies that the provider is complying with payment of income taxes on monies earn as a Medicaid provider.  The Tax Payment Affidavit form is to be completed prior to the meeting in the presence of a notary public. 

Provider Services Calendar

This form is used to track visits and units for each day of the month.

Authorization Agreement

This form is used when a Provider selects Direct Deposit option for reimbursement.

Provider Change of Information Form

This form is used when a provider changes address, phone number or e-mail

CMS-POC 485 Instructions

CMS-POC 485 Example Page

CMS-POC 485 Form

This form may be used as a Plan of Care

Certificate of Medical Necessity - Home Care Certification Form

This form is used to certify the needs for Increased Home Health Services and/or Private Duty Nursing Services.

Personal Care Aide Service Decline Form

Providers may elect not to furnish specific services. Provider must notify CareStar in writing of the services the provider elects not to furnish.

Consumer & Provider Fall Prevention Packet

Weekly Fall Risk Checklist

Monthly Fall Risk Checklist

Wheelchair Version Weekly Fall Risk Checklist

Starting on August 1, CareStar will begin to utilize a special fall prevention protocol.

Ohio Home Care E-Manual

This document contains all the rules for the Ohio Home Care Program.

Quick Index:

Enrollment Process - Page 50

Ohio Home Care Waiver Definitions - Page 62

Condition of Participation for Providers - Page 67

Billing Instructions - Page 133