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Region 3b
Application
Provider Network Application
Step 1
Step 2
Step 3
Step 4
Step 5
Organization Name
*
Name Of Primary Contact For On-Going Communication Between Provider and OCOK
First Name
Name Of Primary Contact For On-Going Communication Between Provider and OCOK - Last Name
Last Name
Title of Primary Contact for On-Going Communication Between Provider and OCOK
Name of Person Completing this Form
First Name
Name of Person Completing this Form - Last Name
Last Name
Title of Person Completing this Form
*
Main Phone Number
*
Fax Number
Mailing Address
Mailing Address
Address 1
Address 1
Address 2
Address 2
City
City
State
Alabama
Alaska
Arkansas
Arizona
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
State
Zip
Zip
Address for Claims Payment (if different from above) City
Address for Claims Payment (if different from above) City
Address 1
Address 1
Address 2
Address 2
City
City
State
Alabama
Alaska
Arkansas
Arizona
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
State
Zip
Zip
Email
*
Please select the following that apply (At least one option must be selected)
Federal Tax ID #
State Tax ID #
Vendor ID #
Federal Tax ID #
State Tax ID #
Vendor ID #
Is the organization a Medicaid Provider?
Have you completed the Subcontractor Consent Form?
Professional Liability Policy Number
Current Independent Carrier Name
Current Independent Carrier Address
Current Independent Carrier Address
Address 1
Address 1
Address 2
Address 2
City
City
State
Alabama
Alaska
Arkansas
Arizona
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
State
Zip
Zip
Current Policy Begin Date:
Current Policy End Date:
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