Get Oh Ins5035 2021-2025

The OH INS5035 is an important application for accreditation as an Independent Review Organization (IRO) in Ohio. By completing this form accurately, applicants can ensure compliance with state regulations and maintain their accreditation status. This guide provides clear, step-by-step instructions on how to fill out the form online effectively.

Follow the steps to complete the OH INS5035 application

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred digital editor.
2. Begin with the 'General Information' section. Provide the legal name of your applicant entity, type of entity (corporation, partnership, etc.), and the Federal Tax Identification Number.
3. Next, fill in the contact person's name and title, along with their phone number, business address (street, city, state, and zip), and mailing address if different.
4. Indicate the state of incorporation and list all other states where the applicant is approved to conduct independent reviews.
5. Identify all accreditations held by the applicant. If the applicant has been refused or lost approval to perform independent reviews, provide explanations in the respective fields.
6. Attach relevant organizational documents, including internal structure charts, contractual arrangements, and articles of incorporation if applicable.
7. For partnerships, include details of all partners, and for organizations classified as 'other,' attach appropriate documentation.
8. Complete the biographical information section for each director or officer of the applicant and any controlling entity.
9. If applicable, provide information regarding the applicant’s ability to conduct business in Ohio, including documentation related to foreign entities.
10. Fill out the anticipated revenues section, detailing sources of revenue derived from the IRO's operations.
11. Review all completed sections, ensure all attachments are included, and certify the application by signing and dating the form.
12. Finally, save your changes, download a copy of the filled form, print it if necessary, or share it as required.

Complete your OH INS5035 application online today to ensure timely submission.