Mandatory Fields
Optional or Conditionally Mandatory Fields
Applicant's Last Name
Applicant's First Name
MI
Social Security #
Phone #
Email
Eligibility Requirements – If you have transitioned through the HOME Choice program since July 2019 you are not eligible to reapply. To qualify for this program, you must be at least 18 years of age, have needs that can safely be met in a home or community-based setting as determined by the Ohio Department of Medicaid or its designee, and meet each of the additional four requirements listed below .
1. You must have active Medicaid benefits at the time of application, and throughout HOME Choice program involvement.
2. You must have income or a means of support for such ongoing expenses as rent, utilities, food, etc. (please check all that apply)
3. You must be legally permitted to leave the institution and relocate to a community setting.
If No, please describe the situation (e.g. court ordered placement)
4. You must have been in one of the following types of long-term care facilities at the time of application for at least 90 consecutive days: a nursing facility (nursing home) or a hospital.
If you were in other facilities for care during the past 90 continuous days please indicate these below in the descending order of stay period.
What circumstances led you to be in your current long-term care stay?
What type of housing did you live in just before being in long-term care?
Have you received any of these specific services in the community?
Do you plan on transitioning to the community within the next six months
Do you have housing to live in once you leave long-term care?
Do you have friends or relatives who can help you transition to the community?
Do you have friends or relatives who can help you after you transition to the community?
Are you a past Medicaid waiver recipient?
I understand that participation in the Ohio HOME Choice program is voluntary; therefore, if approved, I understand and agree to the following responsibilities as a participant in the HOME Choice program:
(Each box must be checked to be eligible for program and you must agree with each individual statement.)
If the applicant has a guardian, please complete this section.
If the application is completed by person other than the applicant, please complete this section.
