Get Oh Ins 5036 2011

Completing the OH INS 5036 is essential for credentialing agency, program, or organization providers in Ohio. This guide provides clear steps to help you fill out the form accurately and efficiently in an online format.

Follow the steps to successfully complete the OH INS 5036 online.

1. Click ‘Get Form’ button to obtain the OH INS 5036 and access it in your preferred online editor.
2. Begin by filling out the provider identification section. Include the legal name of the applicant, Federal Tax Identification Number, and any names under which you do business (DBA). Address details, including primary office address and mailing address, should be filled out without leaving any blank spaces.
3. In the credentialing contact section, provide the name, phone number, fax number, and email of the individual who will be handling credentialing requests.
4. Complete the provider practice information section. Be sure to include operational hours and confirm whether your information is included in the provider directory.
5. Fill out the billing information section with details on billing address and the type of claim form used.
6. Provide accreditation status and any relevant licenses or certifications. Indicate the status of Medicaid and Medicare provider numbers, along with any CLIA numbers.
7. In the scope of services section, list all services offered by your organization and confirm details such as the availability of a toll-free number and if the facility is staffed 24/7.
8. Complete the sections on liability insurance, staffing, electronic capabilities, and disclosure questions. Ensure to check each statement carefully and provide necessary explanations if needed.
9. Add references as required. Provide names, companies, addresses, and phone numbers of healthcare providers, organizations, or managed care organizations that the provider currently services.
10. After completing the form, save your changes, and prepare to download or print the finished document for distribution, particularly to health plans and other credentialing entities.

Complete your OH INS 5036 application online today to ensure your credentialing process proceeds smoothly.