Oha 3973 form-2026

1. Click ‘Get Form’ to open the OHA 3973 form in the editor.
2. Begin by entering your provider name and location in the Identifying Information section. Ensure accuracy as this is crucial for enrollment.
3. Fill in your nine-digit Social Security Number (SSN), Date of Birth (DOB), and Tax Identification Number (TIN). Attach necessary documentation, such as the IRS confirmation letter.
4. In the Provider Certifications section, answer questions regarding any sanctions or disciplinary actions. If applicable, provide explanations on additional pages.
5. List ownership or control interests by providing names, SSNs, DOBs, and addresses of individuals with significant ownership. Use additional pages if necessary.
6. Complete the Criminal Offenses section by detailing any relevant convictions related to public assistance programs.
7. Finally, sign and date the form in the Provider Signature section to certify that all information is accurate.

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