Out-of-State Medicaid Justification Form

Per the Ohio Department of Job and Family Services contract for services C-1213-07-0043, Article 1, A(4), in accordance with Ohio Administrative Code 5101:3-2-07, only extra renal organ transplants to Ohio Medicaid consumers, that cannot reasonably be performed in Ohio, will be sent out-of-state. The following information is needed as justification for your Ohio Medicaid patient seeking extra renal organ transplantation outside the state of Ohio.

Please use the Out-of-State Medicaid Justification Form if you are a non Ohio center requesting approval for organ transplant.