Provider Enrollment Application - The Oklahoma Health Care Authority
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1SOONERCARE PROVIDER APPLICATION
BUSINESS
FOR
- Application must be typed or printed in black ink. All information must be completed or marked "N/A".
- When completeing this application, keep in mind the questions pertain to the organization named in the agreement.
- Provide evidence of current professional liability (malpractice) insurance policy.
- Enrollment in the VFC Program is required for those who provide primary care for members under 18 years of age.
- If you have any questions regarding this application, please contact Provider Enrollment at (800)522-0114, option 5
or locally at (405)522-6205, option 5.
OKLAHOMA MEDICAID INFORMATION
Are you currently or have you ever been enrolled in the Oklahoma Medicaid Program?
Yes, I am currently enrolled.
Yes, I was in the past. Go to Section II.
No. Go to Section II.
If currently enrolled, please check one of the following:
Change of ownership.
Change Effective Date ___________________ Current Provider ID __ __ __ __ __ __ __ __ __ __
Additional service location.
Effective Date ________________ Current Provider ID(s) _________________________________________
(If the first 9 digits are the same, only list once.)
Other __________________________________________________________________________
Effective Date ___________________ Provider ID __ __ __ __ __ __ __ __ __ __
PROVIDER INFORMATION
Corporation
Estate/Trust
Government Owned
Limited Liability Company
Not-for-Profit
Partnership
Public Service Corporation
Sole Proprietor
___________________________________________________________________
__ __ __ __ __ __ __ __ __ __
DBA
Name
NPI
(Doing Business As)
(National Provider Identifier)
__________________________
_________________________________
____________________________
First DOS
Medicare Number
Medicare Certification Date
(Date of Service)
______________________________________
____________________
__ __ __ __ __ __ __ __ __
License Number
Original Issue Date
DEA Number
(Attach a copy of current license)
Are you enrolled in the Vaccine for Children (VFC) Program?
Yes
No
VFC #_______________
ADDRESS INFORMATION
______________________________________________
______________________________________________
Service Location Address
Pay To
(PO Box is not acceptable)
(If different from Mailing on Section 2.2 of the agreement)
______________________________________-_______
______________________________________-_______
City
State
Zip
4 digit zip
City
State
Zip
4 digit zip
(_____)________________(_____)__________________
(_____)__________________(_____)________________
Phone
Fax
Phone
Fax
____________________________________ (________)_____________________ (________)________________
Contact Name
Contact Phone
Fax
______________________________________________
E-mail Address
PAYMENT AND TAX REPORTING INFORMATION
FEIN
__ __-__ __ __ __ __ __ __
(Federal Employer Identification Number)
IRS
Legal Name____________________________________________________________
(Internal Revenue Service)
(Must match with IRS Form SS4 or IRS Letter 147C. A copy should be attached.)
If you are a Sole Proprietor and do not have a FEIN, SSN
can be used instead.
)
(Social Security Number
SSN __ __ __-__ __-__ __ __ __
Name as it appears on Social Security Card ________________________________________________________
Last
First
Middle
________________________________
_______________________________
______________________
Print Authorized Representative Name
Authorized Representative Signature
Date
* If you are an eligible primary care provider and choose to enroll as a group Choice and/or O-EPIC Provider,
please complete the applicable attachment(s).
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