Before submitting this form, please download the documents listed below by right-clicking and choosing “save link as” or “save target as.” Once the documents are complete, they must be uploaded to the corresponding upload option below.
NOTE: The contracting process cannot begin unless all documents are submitted and accurate. Prior to submitting, please verify there are no discrepancies in the information provided and the TIN/NPI included on the forms align with documentation submitted to the Ohio Department of Medicaid, if contracting for Medicaid/MyCare.
- If adding a new group practice under an existing TIN–
- Medicaid Attachment C - (if contracting for Medicaid/MyCare)
- New Location Form
- New Provider Enrollment Form(s) to add fewer than 5 practitioners or roster to add 5 or more practitioners to that group/location
- If adding new services under an existing TIN –
- New Provider Enrollment Form(s) to add fewer than 5 practitioners or roster to add 5 or more practitioners to that group/location.
- If adding new products under an existing TIN – no documents are needed
- If adding new products under an existing TIN
If you are only submitting the direct roster for several practitioners please us the upload option for the New Practitioner Enrollment form to attach the roster.