Get Oh Contact Information Form For Ohio Health Plan Issuer (hpi) External Review System Users

Completing the OH Contact Information Form is essential for individuals in your organization who require access to the Ohio Health Plan Issuer External Review System. This guide provides clear, step-by-step instructions to help you efficiently fill out the form and submit it online.

Follow the steps to complete the OH Contact Information Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the Health Plan Issuer (HPI) Name(s) in the designated field. This information is critical for identifying the relevant plan associated with the request.
3. Input the HPI FEIN Number. This unique identifier is necessary for processing your request.
4. Complete the HPI Contact Information section by providing the following fields: Contact Name (First, Last, MI), Email, Phone, and Extension if applicable.
5. Indicate your Job Title and specify whether the contact works for a Third Party Administrator (TPA) on behalf of the HPI. If ‘Yes,’ fill in the TPA Name and FEIN Number.
6. Select the appropriate HPI Contact Role from the list provided. Be mindful that only certain roles can be assigned to non-person email contacts.
7. In the final section, provide details about the Manager/Officer who is authorizing access to the External Review System. Include their Name, Email, Title, Phone, and the Effective Date of this Authorization.
8. Review all entered information for accuracy, then save changes, download, print, or share the filled form as needed before submitting it.

Complete your Contact Information Form online today to ensure your access to the Ohio External Review System.