Job & Family Services -
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ODJFS Office of Legislation - Constituent Inquiries Intake Form ~~
   
    Legislative Aide:
Legislator:    
Phone:
Legislative E-mail Address:    
Constituent Name:
Constituent SSN:
Constituent Address:
Constituent City, State, Zip:
Constituent Phone #(s):
Constituent Daytime Phone #(s):
County:

Application Date:
Caseworker:
Case Number:   

Child's Name & Birthdate (child welfare inquiries only):
Child's Name:
Child's Birthdate:

Provider Number (Medicaid provider billing inquiries only):   

Employer Number (Employers calling about quarterly tax reporting):   

Inquiry:

By clicking the "I agree" button, I understand that ODJFS will contact the constituent named on the form above to answer and attempt to resolve his/her question or concern. ODJFS can inform the person submitting the request that the submission was received and that ODJFS will be completing a response to the named constituent.

Pursuant to section 5101.27 of the Revised Code and 45 CFR 431.300 through 431.306, ODJFS cannot provide constituent specific information to the person submitting this question or concern unless the person submitting the question or concern is the subject of the specific information provided or the person submitting the information provides to ODJFS a legally compliant release of information signed by the subject of the information or authorized representative. Copies of the legally compliant protected health information release form or the general release form can be downloaded from the constituent assistance page.