OH Non-participating Provider Profile
Please complete this form for the provider listed on the attached claim;
CareSource
is unable to process the claim without this information. Please note that this document is for claims purposes only, and does
not
guarantee claims payment.
Provider Name & Credentials:
Medicaid ID:
Medical License Number:
DEA Number:
NPI:
Email:
Primary Specialty:
Board Certified?
Yes
No
Board Eligible?
Yes
No
Secondary Specialty:
Board Certified?
Yes
No
Board Eligible?
Yes
No
1) Primary Practice
Primary Practice Name:
Address:
City:
State:
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP:
Phone:
Fax:
Federal Tax ID:
Name of entity reimbursement is to be made payable to:
Entity's NPI:
Billing Address:
City:
State:
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP:
Billing Phone:
Billing Fax:
Contact Person:
Email:
All other correspondence should be mailed to:
Practice
Billing
Other
Other
2) Secondary Practice
Secondary Practice Name:
Address:
City:
State:
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP:
Phone:
Fax:
Federal Tax ID:
Name of entity reimbursement is to be made payable to:
Entity's NPI:
Billing Address:
City:
State:
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP:
Billing Phone:
Billing Fax:
Contact Person:
Email:
All other correspondence should be mailed to:
Practice
Billing
Other
Other
Add Another Practice
NOTE: PLEASE ATTACH A W-9 FORM FOR THE TAX IDENTIFICATION NUMBER LISTED ON THIS FORM.
Selecting a new attachment replaces the current one.
November 2023
OH-P-148b
Provider Operations
P.O. Box 4135
Dayton, OH 45401-4135
Phone: 1-800-488-0134
Fax: 1-937-531-3910
