Information Request Form for Provider Inquiries

Provider Inquiry Form

Information Requests, please complete one form per consumer inquiry.
Name of Agency*
Contact Name*

First NameLast Name
Contact E-mail*
example@example.com
Contact Phone Number*

Area CodePhone Number
NOTICE! Questions or status on enrollment into MyCare Ohio Waiver must be directed to those plans. The ADRC does not have information on MyCare member enrollment status.

MyCare Buckeye: (866)549-8289
MyCare CareSource: (855)475-3163
MyCare United: (877)542-9236
Reason for Request*
Consumer Name*

First NameLast Name
Consumer Date of Birth*

MonthDayYear
Date
Consumer Medicaid Number if Known
Which Waiver Is Consumer Enrolled in?*

PassportAssisted LivingMyCare Buckeye/ Ph: (866)549-8289MyCare CareSource/ Ph: (855)475-3163MyCare United Healthcare/ (877)542-9236
NOTE: Please allow 2 business days for a response to your inquiries.
Should be Empty:

Provider Inquiry Form