Omhsas healthchoices bh mco attestation form and attachments 2026

1. Click ‘Get Form’ to open the omhsas healthchoices bh mco attestation form in the editor.
2. Begin by selecting the action requested: Initial Enrollment, Service Location Change, or Fee Assignment. Ensure you check the appropriate box based on your situation.
3. Fill in the Enrollee’s Name section with the applicant's name and date of birth. If applicable, attach a copy of your fictitious business name statement.
4. Enter Tax Identification Information (TIN) by providing your Social Security Number and Tax Identification Number. Attach necessary documents as specified.
5. List your National Provider Identifier (NPI) number and taxonomy(s). Remember to include a copy of your NPPES confirmation letter.
6. Indicate your Business Type by checking the appropriate box and attaching any required corporation papers or partnership agreements.
7. Identify the BH-MCO network you will participate in and list all counties you are approved to serve.
8. Check the types of supplemental services for which you are applying, ensuring to attach relevant licenses or certificates as needed.
9. Complete all sections regarding Confidential Information, Physical Service Location, Mail To Information, Pay To Information, and Home Office Information accurately.
10. Finally, sign and date the application using black ink. Ensure that all required attachments are included before submission.

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