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Ask your worker.  \nTDD-For the  \nHearing Impaired:  7-1-1   \nPhone:  (844)640-6446   \nPhone Hours:  (M–F) 7AM – 8PM (Sat) 8AM – 5PM (Sun) Closed   \nIt is time to renew your Medicaid coverage.  \nIf you receive Medicaid, Medicare Premium Assistance, Long Term Care, or Waiver services, you must respond to this notice to renew those services.  \nIf you are unable to read English and need this form translated into your preferred language, contact your case worker.  \nPlease call the number listed above for assistance.  \nSi no puede leer inglés y necesita este formulario traducido a su idioma preferido, póngase en contacto con el trabajador a cargo de su caso. Por favor llame al número mencionado arriba para asistencia.  \nHaddii aanad awood u lahayn in aad akhrido oo aad u baahantahay in loo turjumo foomkan luqadda aad doorbidayso, laxidhiidh shaqaalaha kiiskaaga. Fadlan wac lambarka kor ku qoran wixii caawimo ah.  \n\n| You Can Renew Your - Online: If you have an online account, [go to ssp.benefits.ohio.gov](go to ssp.benefits.ohio.gov), logon and click\u003Cbr>Medicaid in any on Renew My Benefits\u003Cbr>one of these ways - By mail: Complete this form and mail it to your local County Department of Job and\u003Cbr>Family Services (CDJFS)* .\u003Cbr>- In person: Visit your local CDJFS*\u003Cbr>- By phone: (844)640-6446\u003Cbr>*Find the address to your local office at: [jfs.ohio.gov/county/county_directory.pdf](jfs.ohio.gov/county/county_directory.pdf) |  |\n| --- | --- |\n| How to complete this renewal form | 1. Answer all of the questions on the form. If you do not have all of the information asked for, still sign and submit this form.\u003Cbr>2. Add any missing information. If any information has changed, cross out the old information and write in the new information. If you need more space to provide additional information about yourself or someone in your household or on your tax return, print copies of the page or write the information on a separate sheet of paper and attach it to this form.\u003Cbr>3. Sign the form on page 9.\u003Cbr>4. Respond to this form by . If you do not respond to this form by the deadline, you will lose your Medicaid coverage. |\n| What we need | Information about each person living in your household or listed on your tax return including employer and income information, for example: information from pay stubs, W-2 forms, or wage and tax statements AND policy numbers for any current health insurance. |\n| What happens next? | We will process your renewal. If you do not hear from us in 1-2 weeks, call\u003Cbr>(844) 640-6446 |\n\nIf you, someone in your household or on your tax return is not already on Medicaid and would like to apply for health insurance, a new application must be completed. You can apply online at healthcare.gov or benefits.ohio.gov or by calling (844)640-6446 or in person at your local CDJFS.  \nPage 2  \n 1  Your contact information  \n\n| Home Address:\u003Cbr>Mailing Address:\u003Cbr>Phone: |  | Name (first, middle, last & suffix) |\n| --- | --- | --- |\n|  |  | Home Address Apartment \\# |\n|  |  | City (home) State Zip code |\n|  |  | Mailing Address Apartment \\# |\n|  |  | City (mailing) State Zip code |\n|  |  | Best phone number to reach you: Home Cell  Work |\n|  |  | Number: |\n|  |  | Other phone number, if you have one: Home Cell Work |\n|  |  | Number: |\n| Email Address: |  |  I want to receive information by email |\n| Voter Registration Application Attached-Help completing this form is available if you need it.\u003Cbr>If you are not registered to vote where you live now, would you like to apply to register to vote today? If you do not check either box, you will be considered to have decided not to register to vote at this time.\u003Cbr> YES, I want to register.  NO, I do not want to register to vote. |  |  |\n| Do you want to apply for any of the following programs?\u003Cbr> Healthy Start & Healthy Families (Medicaid)  Nutritional Program for Women, Infants & Children (WIC)\u003Cbr> Chi","cbCaimg2rvuDYkPr","https://ap.wps.com/l/cbCaimg2rvuDYkPr","pdf",115328,13,"English","# Medicaid Renewal Notice\n## Response deadlines and assistance options\n## How to complete the renewal form\n## Information needed and next steps\n# Renewal form sections\n## Contact information\n## Voter registration and program requests\n## Tax return filer information\n## Household member details","[{\"question\":\"What action is required to keep Medicaid coverage active?\",\"answer\":\"Complete and submit the Medicaid Renewal Form by the deadline. If you do not respond by the deadline, your Medicaid coverage will be lost.\"},{\"question\":\"Where can applicants submit the renewal form?\",\"answer\":\"Renew online using an online account, or submit by mail, in person, or by phone. The form also provides the customer service phone number and instructions for locating the local county office address.\"},{\"question\":\"What information is needed to complete the renewal?\",\"answer\":\"Provide information about each household member, including employer and income details (such as pay stubs or W-2s), any current health insurance policy numbers, and tax return filer information. The form also requests dates of birth and Social Security numbers for the listed people.\"}]","Medicaid Renewal Form - Renewal Instructions and Required Information | PDF",1789835643]