Caqh Provider Data Form
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1Molina Healthcare of Ohio
CAQH Provider data Form
for Credentialing Purposes
Ohio Revised Code 3963.05 prescribes the credentialing form used by the Council for Affordable Quality Healthcare (CAQH) as
the required credentialing application for physicians.
If you participate in CAQH:
To begin the Credentialing process, please complete this CAQH Provider Data Form and submit it to Molina Healthcare of Ohio, Inc.
If you are not participating in CAQH:
Please complete this CAQH Provider Data Form and return it to Provider Information Management at Molina Healthcare of Ohio, Inc.
A CAQH number will be generated, and your office will be notified. Once you receive your CAQH number, it is your responsibility
to complete the on-line CAQH Provider Application and include all appropriate documents and notify Molina. You may access the
CAQH website at Click on Providers UPD Login and Information, and follow the first time log-in instructions.
The CAQH Support Desk can be reached directly at 1-888-599-1771 to assist in the resolution of any issues regarding CAQH participation.
Last Name:
First Name:
Middle Initial:
Provider Type:
Last 4 digits of
Provider NPI#:
Provider SS#:
(MD, DO, DC, DDS, DMD, DPM, etc.)
Date of Birth:
E-Mail Address:
_____/_____/_____
Primary Telephone Number:(
)
Primary Fax Number:(
)
Group Name:
Primary Office Street Address:
Suite#:
Primary Office City:
State:
County:
Zip:
Specialty:
Applying as:
☐ PCP
☐ Specialist
☐ Allied Health
Professional
Are you board certified?
☐ Yes
☐ No
If Yes, board name:
Are you registered with CAQH?
☐ Yes
☐ No
If Yes, CAQH Provider ID:
Authorized Signature:
date Signed:
Please return via fax to 866-713-1893, email: , or mail to the address below to Attn: PIM
: If you have already completed your application with CAQH, please ensure that you have authorized all applicable organizations to
NOTE
access your data. Using the CAQH Universal Credentialing Data Source does not constitute applying for participation with any healthcare
organization. If applicable, please contact the health plan directly to request contracting information. Please make sure that your CAQH
information is updated and completed.
Molina Healthcare of Ohio, Inc. • P.O. Box 349020, Columbus, OH 43234-9020
7007OH1011
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