Written by a parent, not a doctor. Nothing here is medical advice.

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Ohio Department of Health

Complex Medical Help (CMH)

What you get

Help with approved hospital diagnosis, surgery and stays, X-rays, tests, doctor visits, medicines, public-health nursing, care coordination, therapy evaluations, therapies and medical equipment. Open now.

Who starts it
You, with their part of the form from your doctor
How it’s sent
PDF form, sent the way they ask
Your time
About 30 minutes, plus waiting for the form
Last checked
Aug 27, 2026

Before you start, check you fit

  • Your child is 25 or under.
  • CMH does not cover every service your child may need.
  • A CMH-approved physician is required for the medical application.

  1. Ask your doctor for their part of the formStart here. This is the part that takes the longest.

    Ohio Department of Health needs 2 things from your doctor. It has to cover one thing. Copy this message, or say it in person at the next visit.

    Hi [doctor’s name],

We’d like to apply to Ohio Department of Health’s Complex Medical Help (CMH). They offer help with approved hospital diagnosis, surgery and stays, X-rays, tests, doctor visits, medicines, public-health nursing, care coordination, therapy evaluations, therapies and medical equipment, and they are taking applications now.

They need 2 things from you: their part of the form and a note confirming the diagnosis. It has to cover other medically relevant conditions. Their form and instructions are here: https://pickawaycountypublichealth.org/site/clinical-health/complex-medical-help/

Could you do that when you have a chance? I’ll bring the printed form to our next visit, or I can email it. Thank you for everything you do for us.

[your name] · [phone]
    Copying is the only thing this page does with your text. Nothing is saved.

  2. Fill in their formPrint it, or fill it in on screen if the PDF allows.

    Open the application PDF ↗ Checked Aug 27, 2026

    What the form asks for

    MAF child, family, contact, and insurance information
    Diagnostic / Treatment / Case Renewal / Service Coordination / PHN Referral / Adult Hemophilia / Adult Cystic Fibrosis / Metabolic Formula ProgramChild's/Client's name; case number; address; city; state; ZIP; county; e-mail addressChild's/Client's birthdate; Social Security number; sex; ethnic group; Ohio residentParent's/Legal guardian's/Client's name; address; city; state; ZIP; Social Security number; home phone; work phoneHealth, dental, and vision insurance coverage; policy/carrier numbers and dates; company and insured names; Medicaid eligibility and recipient/billing number; S.S.I. eligibility
    Managing physician, diagnoses, requested services, and treatment plan · your care team fills this in
    Managing physician's/Service coordinator's name; site; address; telephone number; provider numberPrimary, secondary, tertiary, and quaternary diagnosis and I.C.D. codeIf child/client has any other handicapping condition(s), please describeName of primary care physician; Name of primary care dentistMajor Services Requested: Category of service; Name and address of provider; Recommendations (Include/attach plan of treatment, medical report and/or discharge summary.)Managing physician's/Service coordinator's signature; date; print physician's name; initial date of exam; name and telephone of person completing form; most recent date of exam
    CMH Financial Application sections A through F
    First Name of Parent/Guardian/Client (18 years or older); Middle Initial; Last Name; Relationship to Client; Street Address; City; State; Zip; County; Home Phone; Work Phone; Mobile PhoneMarital Status; Currently Pregnant; Due Date; Number of unborn childrenFor each person living with you: Full Name; Date of Birth; Pregnant; Due Date; Ohio Resident; Social Security number; Relationship to Client; Female/Male; Number of unborn children; CMH Client; CMH Client Number; Primary LanguageName; Employer or Source of Income; Gross Amount; How often ReceivedDoes anyone in your household pay for someone to care for your children while you are at work or school? If yes, attach verification; Amount paid per weekNew/current insurance: company and phone; insured name; effective date; monthly premium; policy and group numbers; prescription benefit and mail-order pharmacy; prescription administrator; dental/vision insurance and administratorsSecondary insurance: company and phone; insured name; effective date; monthly premium; policy and group numbers; prescription benefit and mail-order pharmacy; prescription administrator; dental/vision insurance and administratorsI, (Client's Name), give permission to CMH to release information and/or discuss my case with (Name and Relationship to Client)Parent/Legal Guardian/Client Signature; Relationship to Client; Date
    MAF and separate release/consent details
    Child's/client's name; List all children in home currently involved with BCMH; Case number; Birth date; County of residenceIf the 18-year-old is unable to sign, provide a written explanation regarding the reason that the 18-year-old cannot signClient's Name - Please Print; Give permission to CMH to release information and/or discuss my case with: Name; Relationship to Client; DateParent/Legal Guardian/18 y/o Client Signature; Relationship to Client; DateBest time of day to contact me; alternate contact name, relationship, and telephone

    Have ready

    • Completed CMH Financial Application, unless the applicant receives Ohio Medicaid benefits.
    • Three current pay stubs with year-to-date gross and any additional requested income verification.
    • Most recent federal tax return, including Schedule 1 when applicable.
    • If the household pays for child care while working or attending school, receipt, canceled check, or provider letter showing the amount paid per week.
    • Only if ODH requests it: proof of paid, unreimbursed medical, dental, or other expenses, such as receipts, canceled checks, or physician statements.
    • Information and supporting evidence about health, prescription, dental, vision, Medicaid, and other third-party coverage when applicable or requested.
    • Completed release and consent signed by the parent, guardian, or adult patient.
    • If an adult client cannot sign and a parent or legal guardian signs instead, court documentation appointing the parent as guardian.

  3. Send it the way they ask

    • The managing physician submits the signed MAF, individualized treatment plan, and necessary medical reports to ODH. The family submits the signed financial application, release/consent, pay stubs, tax return, and applicable supporting documents to the mail, fax, or email destination printed on the current form.

After you send

Keep a copy and proof of submission. Respond to physician-side requests within 30 days and family financial-information requests within 60 days of the request letter. ODH publishes a determination notice within 30 days after the last necessary document is received. If you have not heard back by then, write and ask.

Full record, as published