Loading
Get Ohio Fillable Credentialng Form
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Ohio Fillable Credentialing Form online
Filling out the Ohio Fillable Credentialing Form online is a straightforward process that requires attention to detail. This guide will walk you through each section of the form, ensuring you provide the necessary information accurately and completely.
Follow the steps to successfully complete the credentialing form.
- Press the ‘Get Form’ button to access the form in your browser.
- Fill in the 'Provider Identification' section. Include details such as the legal name of the applicant, Federal Tax Identification Number, and any alternate names (DBA). Ensure all fields are completed with current and accurate information.
- Complete the 'Provider Practice Information' section. Provide your primary office address, contact numbers, and confirm if your practice has handicapped access and is on a bus route.
- If applicable, fill out additional practice locations by repeating the previous step. Include details for each location, ensuring you provide separate NPI numbers and addresses where necessary.
- Provide billing information, specifying to whom checks should be made payable, the billing address, and the types of claim forms used (e.g., CMS1500, UB04).
- In the 'Licensure and Certifications' section, indicate your license numbers, statuses, and any accreditation details relevant to your credentialing.
- Detail the 'Scope of Services' offered by your provider agency, noting any 24/7 staffing or specific patient acceptance criteria.
- Provide comprehensive information regarding your liability insurance, including coverage types and effective dates. Attach any necessary documentation.
- Respond to the disclosure questions honestly, providing detailed explanations for any affirmative answers on separate attached sheets when required.
- Fill out the 'References' section with at least three contacts from health care providers or organizations to confirm your services.
- Review all completed sections for accuracy. Once satisfied, save your changes and choose to download, print, or share the form as needed.
Start completing your credentialing documents online today!
To credential a provider, you need their personal identification details, professional qualifications, and relevant work history. This information ensures that the provider meets both legal and professional standards. Leveraging the Ohio Fillable Credentialing Form can facilitate gathering and organizing this essential information, helping providers meet the credentialing requirements easily.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.