Long-Term Care (LTC) - Contact Form

 

The Long-Term Care (LTC) Contact Form is to be used by organizations representing Long-Term Care Customers only. Richland County Job & Family Services will respond to organizations designated as an Authorized Representative by their customer. If Authorized Representative status and identification cannot be verified, we are not able to respond. 

 

 

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Organization Name: This field is required
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Authorized Representative Name: This field is required
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A valid email address is required

Authorized Representative Address:

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Client Name: This field is required
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Client Address:

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How may we help you?
Documents (may be uploaded to the Ohio Benefits Self-Service Portal at https://benefits.ohio.gov/home, faxed to 419-774-0051 or dropped off at the agency)