Web Content Viewer

J-1 Visa Waiver Program Patient Activity Report

The Patient Activity Reporting form is due each January 15 and July 15 showing payer mix data for the prior six month period, i.e.: data for January – June is due July 15 and data for July – December is due January 15.  

Click the 'Download' button on this page to download the Patient Activity Report document.

Please submit the completed form to PCRH@odh.ohio.gov.