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Medical provider, behavioral health provider, or pharmacist who will be billing under his/her own Tax ID (TIN) or Social Security Number (SSN), along with a Type 1 (individual) NPI (NOTE: If you are a person joining an existing group, please complete a New Practitioner Enrollment form located at Buckeye Health Plan website.

Please select the products for which you wish to contract * Medicaid MyCare (Medicaid and Medicare duals for Ohio) Medicare Marketplace (Ambetter)

Please select the services for which you wish to contract * Medical Behavioral Health Medical and behavioral health Home and Community Based Services (HCBS) Waiver

Tax ID to be included in contract* (Must match the Tax ID used for enrollment with the Ohio Department of Medicaid, if contracting for Medicaid/MyCare) * Numbers only

Provider First Name as appears on the Form W-9 *

Provider Last Name as appears on the Form W-9 *

Individual NPI (Must match the NPI used for enrollment with the Ohio Department of Medicaid, if contracting for Medicaid/MyCare) * Numbers only.

Taxonomy

Ohio Medicaid ID (Must have an active Ohio Medicaid ID to begin the contracting process, if contracting for Medicaid/MyCare) * Numbers only

Medicare

Correspondence Name/Title *

Correspondence Email *

Correspondence Address *

Correspondence City *

Correspondence State *

Correspondence Zip *

Primary Practice Location Street *

Primary Practice Location City *

Primary Practice Location State *

Primary Practice Location Zip *

Primary Practice Location County *

Contact Name *

Contact Phone Number *

Contact Fax *

Contact Email *

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.

Medicaid Attachment C (PDF) (if contracting for Medicaid/MyCare)
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 Ohio Secretary of State.
New Provider Enrollment Form (PDF)
New Provider Location Form (PDF)

Medicaid Attachment C Form *

Disclosure of Ownership Form *

W-9 *

New Provider Enrollment Form

New Provider Location Form