Ohio ACE - Qualified Education Service Provider - Marketplace Listing Edit Request Form

Ohio ACE - Qualified Education Service Provider - Marketplace Listing Edit Request Form

This form is identical to the one you completed to register with the Ohio ACE program. However, in this version, all form fields are optional, so please complete only the fields you wish to change from your original submission. Please allow up to 3 weeks for edits to take effect.
Info about you

You must be listed as an administrator by your Organization to complete this registration form. If you are unsure if you are listed, please contact qesp-help@aceohio.org prior to filling out this form.
Name of individual filling out application*

First NameLast Name
Phone Number of individual filling out application*
This will not be public, it will only be used to contact you about your registration.Format: (000) 000-0000.
Email of individual filling out application*
This will not be public, it will only be used to contact you about your registration.
Your Role or Position at Organization*
Is there an additional person from your organization that should be able to review claims?
Please fill out the Ohio ACE - QESP Claim & Administrator Updates form to add additional claim reviewers or administrators.
Point of contact to add to review claims

First NameLast Name
Info about your Organization
Organization Name*
Provide name as listed on business license or other government issued documentation.
Qualified Education Service Provider Number *
You can find this in your application confirmation email, or the marketplace at aceohio.org/marketplace
Is your Organization a franchise, or have multiple locations?
Please provide a unique name for your franchise (i.e. Branch number or location)*
What would you like to update about your organization?*
Please complete the following fields with the information you would like to update about your organization. Most fields are optional; only complete the ones for which the information has changed.
Organization Website
Organization Phone Number
Will be publicly listed for parents/guardians to contact you.Format: (000) 000-0000.
Organization Email
Will be publicly listed for parents/guardians to contact you.
Organization Administrator Email
Use this field to change the administrator of your organization on the Merit platform.
Changing Administrators

Please fill out the Ohio ACE - QESP Claim & Administrator Updates form to add additional claim reviewers or administrators.
Primary Address

Street Address

Street Address Line 2

CityState

Zip Code
Is your Primary Address the same as your Service Address?
Service Address*

Street Address

Street Address Line 2

CityState

Zip Code
Organization Listing
Organization Description

Please provide a description of your organization and the services you offer. This will be publicly shown on your marketplace listing. help.aceohio.org/may-2023-ace-program-clarifications0/500
Which of the following approved services does your organization provide?
Please explain how your organization provides these services?

0/500
Do you offer services for children with special needs or disabilities?
Please describe the services offered for children with special needs or disabilities.
What is the lowest cost service you provide? (The lowest price cannot be $0 or specifically targeting ACE students)
What is the highest cost service you provide?
Which grades does your organization serve?
Which Ohio regions do you serve?
Do you bill/invoice customers and allow them to pay at a later date?
Invoiced customers would not need to pay upfront and your organization would be reimbursed directly from ACE Ohio after the parent submits a claim. Note that invoicing should be an additional payment option and not a substitute for receipts.
Organization Logo

This will be the primary photo used for your marketplace listing.
Cancelof
Supporting Documents

Please upload any documents associated with a service/policy/price change. Failure to do so could result in your marketplace update being denied.
Cancelof
Please verify that you are human*
Should be Empty:

Ohio ACE - Qualified Education Service Provider - Marketplace Listing Edit Request Form

Info about you

Info about your Organization

Changing Administrators

Organization Listing