Application

Provider Network Application

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

Address 1

Address 2

City

State

Zip

Address for Claims Payment (if different from above) City

Address 1

Address 2

City

State

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

Address 1

Address 2

City

State

Zip

Current Policy Begin Date:

Current Policy End Date: