Ohio department of insurance standardized credentialing form 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with the 'Provider Identification' section. Fill in the legal name, Federal Tax Identification Number, and any applicable DBA. Ensure all fields are completed without leaving blanks.
3. Proceed to 'Provider Practice Information'. Enter details such as the primary office address, contact information, and operational hours. If there are multiple practice locations, ensure each is documented separately.
4. In the 'Billing Information' section, specify to whom checks should be made payable and provide the billing address. Select the type of claim form used from the options provided.
5. Complete the 'Accreditation Status' and 'Licensure and Certifications' sections by providing relevant numbers and statuses for Medicaid, Medicare, and other certifications.
6. Finally, review all sections for accuracy before submitting your completed form directly to health plans or entities that credential providers.

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