OOS Medicaid Services

Secure Eligibility Verification Submission

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Fill out the form to create a new eligibility verification for processing.

NOTE: Eligibility Verifications may be submitted 24/7 through this website. If an EV is received outside regularly scheduled hours, our staff will respond promptly during the next business day.
***For contracted client use only***

Hospital Information

Facility Name required
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Contact Name required
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Contact Phone required
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Contact Email
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Contact Department
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Patient Information

LAST Name required
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FIRST Name required
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Patient Medicaid State required
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Medicaid ID
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Medicaid Card on File required
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Birthdate required
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Gender required
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Social Security Number
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Account Number / FIN required
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Visit Information

Visit Type required
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Service Start Date required
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Service End Date
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Reason for Visit required
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Additional Information

Comments
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Notify By required
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