Get Oh Mho-0443 2014-2025

Filling out the OH MHO-0443 form is an essential step for providers seeking to join Molina Healthcare of Ohio's network. This guide will help you navigate each section of the form, ensuring a smooth online submission process.

Follow the steps to successfully complete the OH MHO-0443 form.

1. Press the ‘Get Form’ button to access the OH MHO-0443 form and open it in the editor.
2. Complete the 'Provider Name' field by entering the full name of the provider applying for contract.
3. Fill in the 'Provider Type/Specialty' section, specifying the relevant specialty of the practice.
4. Enter the 'Medicaid ID Number' that corresponds to the provider.
5. Input the 'Practice Name' under which the provider operates.
6. If applicable, list the names and specialties of all practitioners in the group if this is a group practice. You may attach a separate sheet if needed.
7. Fill out the 'Mailing Address' and, if different, 'Primary Office Location'.
8. Identify the 'County' where the practice is located.
9. Provide the name of the 'Person Completing This Form'.
10. Enter a contact 'Phone' number and the 'Provider TIN' for the practice.
11. Fill in the 'Email Address' to receive any communications regarding your application.
12. Indicate whether all practitioners are employed physicians of the group by selecting 'Yes' or 'No'. If 'No', be sure to follow up on the additional requirements.
13. Include any additional information relevant to your practice in the provided section.
14. Once all fields are completed, review the form for accuracy. You may then save changes, download, print, or share the form as necessary.

Complete your documents online to ensure a prompt response from Molina Healthcare of Ohio.