Get Network Provider Hearing Aid Vendor Contract - State Of Oklahoma - Ok

Filling out the Network Provider Hearing Aid Vendor Contract for the State of Oklahoma is essential for hearing aid vendors seeking to partner with the Employees Group Insurance Division. This guide provides step-by-step instructions to ensure a smooth and efficient submission process.

Follow the steps to successfully fill out the form online.

1. Click ‘Get Form’ button to access the contract and open it for editing.
2. Begin by completing the general information section, which includes the legal name of the facility, the trade name (if applicable), and contact details.
3. Fill in the license information with the relevant state, license number, and expiration date. Attach a copy of the facility's current state license.
4. Complete the accreditation section if applicable, providing details about the facility’s accreditation by the Joint Commission or AAAHC.
5. Provide comprehensive insurance information, including the carrier's name and policy limits. Attach the insurance certificate/face sheet.
6. Provide the Federal Tax ID number and National Provider Identifier number, ensuring all W-9 forms are completed and attached.
7. Detail the physical, mailing, and billing addresses, ensuring they match what will be presented on claims submissions.
8. After filling in all required fields and attaching necessary documentation, review the entire application for accuracy.
9. Finalize your submission by printing, signing, and returning the completed application, signature page, and all required attachments to the specified address.

Complete your documents online to facilitate timely approvals and partnerships.