Follow the steps to fill out the Oha 3972 Pdf online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the individual provider information section. Enter your last name and first name in the designated fields. Make sure to double-check the spelling for accuracy.
3. Fill in your date of birth in the specified format. Next, enter your social security number carefully.
4. Input your title or degree as it appears on your license. If you have a middle initial, enter it in the provided space.
5. In the IRS tax ID type section, select the option that corresponds to your identification, either SSN or another identification type.
6. If you are part of a group practice, please enter the group’s NPI(s) in the appropriate section.
7. Move on to the group/facility information section. Enter the name of your group or facility, and provide the Doing Business As (DBA) name if applicable.
8. Fill in the business IRS tax ID, ensuring that it matches the IRS information on file.
9. In the enrollment information section, select all applicable business types and identification numbers. Input your DEA number, NPI, and any other relevant identification.
10. List your primary specialty and any sub-specialties. If necessary, attach additional documentation listing more specialties.
11. Complete the license and certification information, providing numbers, types, and dates associated with your licenses.
12. Provide your physical service location address, including the street, city, state, and ZIP code. Ensure you use a valid physical address.
13. Enter contact details for yourself or a designated contact person, including phone numbers and email addresses.
14. Finally, review all fields once more for accuracy. Save your changes, download a copy of the form, print it if needed, or share it as required.

Start completing the Oha 3972 Pdf online today for a smoother provider enrollment experience.