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Independent Provider First Name (Please enter the Independent provider name as it appears on the W-9) *

Independent Provider Last Name (Please enter the Independent provider name as it appears on the W-9) *

Legal Entity Name * As listed on the Form W-9

DBA Name

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

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

Independent Provider or Waiver Agency Taxonomy

Independent Provider or Waiver Agency OH Medicaid * Numbers only

Independent Provider or Waiver Agency Medicare

Correspondence Name/Title

Correspondence Email

Correspondence Address *

Correspondence City *

Correspondence ZIP Code *

Primary Practice Street Address *

Primary Practice City *

Primary Practice ZIP Code *

Primary Practice Phone Number *

Primary Practice County *

Contact Name *

Contact Phone Number *

Contact Fax

Contact Email *

Provider Email * (May be displayed in provider directory.)

Join our Network

Waiver-Only Provider