Ohio Medicaid Required Information Form

The following information is required by Ohio Medicaid for patients seeking prior authorization for extra renal transplant. All information indicated is required. Ohio Medicaid will not issue a prior authorization without this required information.  This form must be submitted to the OSOTC as a Word document.

This form may be uploaded to the online review system https://review.osotc.org along with the clinical summary -OR- it may be emailed to: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Please note: This form is only required when Ohio Medicaid is the PRIMARY insurer.