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Ohio standardized credentialing form 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin with the 'Provider Identification' section. Fill in the legal name, Federal Tax Identification Number, and Doing Business As (DBA) if applicable. Ensure all fields are completed without leaving any blank spaces.
- Proceed to 'Provider Practice Information'. Here, provide details about your practice location, including address, phone number, and hours of operation. Indicate if you are included in the provider directory.
- In the 'Billing Information' section, specify to whom checks should be made payable and include the billing address. Select the type of claim form used.
- Complete the 'Licensure and Certifications' section by providing your Medicaid and Medicare Provider Numbers along with their statuses.
- Finally, review all sections for accuracy before submitting. Attach any required documents as indicated in the checklist provided within the form.
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Related links
State Board Licensure and Certification. Use the glossary to review whether an Ohio State licensure or certification program meets the educational requirementsRead more
You must include copies of the following documents, as applicable, with this completed application. Use this checklist as a guide: State License.Read more
Complete signed and dated Sunshine Health Standardized Credentialing Form. . Signed attestation of the correctness and completeness of the applicationRead more