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 you are only submitting the direct roster for several practitioners please use the upload option for the New Practitioner Enrollment form to attach the roster.
