Get Interested Practitioner Request Form - Ohio Health Choice

This guide provides clear and detailed instructions for filling out the Interested Practitioner Request Form for Ohio Health Choice online. Completing this form is an essential step for practitioners who wish to join the Ohio Health Choice network.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering your full name, including first name, last name, and middle initial, along with your professional degree (MD, DO, etc.). Make sure this information is accurate and easy to read.
3. Provide the name of your group or organization, if applicable. If you are applying individually, you may leave this field blank.
4. Enter your primary service location address. Ensure that the address is complete, as it will be used for correspondence.
5. Fill in your primary service phone number. This number should be one at which you can easily be reached.
6. Optionally, provide a fax number if you have one. This might be used for additional correspondence if needed.
7. If your credentialing contact address differs from the primary service location, please enter that mailing address in the designated field.
8. Include the phone number and email address for your credentialing contact. This ensures that the OHC network can reach the appropriate person if needed.
9. Indicate your specialty to help OHC evaluate your application appropriately.
10. List any hospitals where you maintain hospital privileges. This information is useful for your application review.
11. Enter your tax identification number (Tax ID #) and any group or individual identification numbers like NPI and CAQH numbers, if applicable.
12. Once you have completed all sections of the form, review your entries for accuracy.
13. Save your changes. You can download, print, or share the finished form according to your preferences.

Complete your Interested Practitioner Request Form online today to begin the process of joining Ohio Health Choice!