Long-term Care Non-Agency Provider (PASSPORT Waiver)
Read and understand the conditions of participation and service requirements for which you are seeking certification. You can view this information as well as all the current effective rules by clicking on the following link.
Applicants applying to the Ohio Department of Aging to be certified as a non-agency provider for the PASSPORT Medicaid Waiver Program may request certification for the following services:
Choices Alternative Meals
Minor Home Modification
Choices Pest Control
Non-Emergency Medical Transportation
Home Medical Equipment/Supplies
The application process is completed online by selecting the “Apply Now” link below.You will have 120 days from the start of the application process to submit an application.Please upload all required documentation prior to submitting your application.If you do not submit an application within 120 days, your application will expire and you will need to complete a new application.Required documentation can be scanned and uploaded within the application prior to selecting submit.
Documentation you will be required to submit:
Registration with the Ohio Secretary of State. A copy of registration certificate with the Ohio Secretary of State.
Ohio Bureau of Workers’ Compensation Certificate. Copy of current certification in good standing with the Ohio Bureau of Workers’ Compensation.
Certificate of Commercial Liability Insurance. OAC 173-39-02(B)(2)(c) requires a minimum of one million dollars in commercial liability insurance.
Employee Dishonesty or Property Damage Insurance. OAC 173-39-02(B)(2)(d) requires the provider maintain insurance coverage for consumer loss due to theft or property damage and provide written instruction that any consumer may use to obtain reimbursement for a loss due to employee theft or property damage.
Table of Organization: A copy of a table of organization that includes the full name of each position and indicates lines of authority.
Completed and Signed W-9: This form will be provided for download during the online application process.
Ohio Medicaid Provider Agreement for Organization: This form will be provided for download during the online application process.
Proof of Residency: Evidence that applicant/CEO has been a resident of Ohio for the last 5 consecutive years. Acceptable documentation includes: valid driver’s license; notification of registration as an elector; a copy of an officially field federal or state tax form identifying the applicant’s permanent residence; any other document the responsible entity considers acceptable that shows evidence that the applicant has been a resident of Ohio for the past 5 years.
After submission, you will have 90 days to submit all required documentation. If you do not submit all required documentation within 90 days, your application will expire and you will be required to start a new application.
PLEASE NOTE: After the application has been submitted you will be unable to upload any required documentation. You will be need to mail or fax the documentation to our office within the 90 day period.
Ohio Department of Aging
50 West Broad Street, 9th Floor
Columbus, OH 43215
Fax Number: 614-466-9812
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If you continue to have further issues, please contact our office at 614-644-1737.