Join our Network

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, upload to the corresponding upload option at the end of this page.

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.

• Medicaid Attachment C (PDF) (if contracting for Medicaid/MyCare)
• New Practitioner Enrollment Form (PDF) - New Provider Enrollment Form(s) to add fewer than 5 practitioners or roster to add 5 or more practitioners to that group/location. - (Only required for facilities/agencies that have affiliated practitioners, other than community mental health centers and substance use disorder facilities – Examples include FQHCs, RHCs, etc. )
• Standard Direct Practitioner Roster (XLS) - Complete this roster if you are submitting enrollment for several practitioners not related to a CMHC or SUD. New Provider Enrollment Form(s) to add fewer than 5 practitioners or roster to add 5 or more practitioners to that group/location.
• Disclosure of Ownership Form (PDF)
• W-9 (PDF) NOTE:  Please ensure name on line 1 of the W-9 exactly matches the name registered with the Secretary of State.
• Department of Insurance Standardized Credentialing Form Part B (PDF): Agency/Program/Organization Providers for Medicare/Marketplace
• Location Form (PDF)

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 NPI under an existing TIN
  • Medicaid Attachment C (PDF) - (if contracting for Medicaid/MyCare)
  • Department of Insurance Standardized Credentialing Form Part B: Agency/Program/Organization Providers for Medicare/Marketplace (PDF)
  • Standard Direct Practitioner Roster (XLS) - Complete this roster if you are submitting enrollment for several practitioners not related to a CMHC or SUD. New Provider Enrollment Form(s) to add fewer than 5 practitioners or roster to add 5 or more practitioners to that group/location.
  • New Provider Enrollment Form(s) (PDF) to add fewer than 5 practitioners or roster to add 5 or more practitioners to that group/location - Only required for facilities/agencies that have affiliated practitioners, other than community mental health centers and substance use disorder facilities – Examples include FQHCs, RHCs, etc.)
  • New Location Form (PDF)

• If adding new services under an existing TIN – No documents are required

• If adding new products under an existing TIN
  • Department of Insurance Standardized Credentialing Form Part B: Agency/Program/Organization Providers for Medicare/Marketplace (PDF) is required only when adding Medicare or Marketplace to a contract that is currently Medicaid or MyCare only.