Get Oh Ins 9028 2001-2025

The OH INS 9028 is a standardized credentialing form used by health care providers in Ohio. This guide provides a comprehensive, step-by-step approach to filling out the form online, ensuring every section is completed accurately and thoroughly.

Follow the steps to successfully complete the OH INS 9028 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start with Section I, Personal Information. Fill in your name, degree, home address, phone numbers, date of birth, sex, and languages spoken. Ensure all fields are completed as incomplete applications may not be processed.
3. Proceed to Section II, Licensure/Certifications/Registrations. Enter all relevant licensure details, including your Ohio license number and expiration date. If you do not have a number but have applied, indicate ‘application in process’.
4. Move to Section III, Office/Practice Information. Indicate whether this is your primary office, details about the type of care provided, and your office information including address, phone numbers, and email.
5. Continue to Section IV, Professional/Medical Education & Training/Work History. Provide a complete history of your education, training, and work, including any explanations for gaps. Include details for all internships, residencies, and fellowships.
6. In Section V, Professional/Medical Specialty Information, designate your primary and secondary specialties and indicate certification status. If applicable, provide details about boards, certification dates, and whether you wish to be listed in any directories.
7. Proceed to Section VI, Health Care Affiliations. List all health care facilities where you have privileges along with their addresses and your status of privileges.
8. In Section VII, Professional References, supply three references. Ensure that only one can be a current partner or associate.
9. In Section VIII, detail your Professional Liability Insurance Coverage for the past ten years, including the carrier name, address, policy numbers, and coverage amounts.
10. For Section IX, provide information on any malpractice claims history over the last ten years, even if there have been no claims.
11. Answer all questions in Section X, Disclosure Information, with 'yes' or 'no,' providing explanations when necessary.
12. Finally, complete Section XI by signing and dating the affirmation. Ensure all information is accurate to avoid rejection.
13. Once all sections are accurately filled out, save changes, and download, print, or share the form as required.

Complete your OH INS 9028 online today for a smooth credentialing process.