Ohio Medicaid

Ohio's Medicaid Program > Providers > Enrollment > Practitioner   Practitioner Groups Documents   Enrollment Application * IRS W-9 * Homeland Security DMA Form * Group Application Checklist Direct Deposit Authorization Agreement Provider Change of Address Form Medicare Information Request Form Clinical Laboratory Improvement Amendments (CLIA Registration) Group Information Form Glossary of Enrollment Terms * Required documents for enrollment   For additional information please contact: Provider Enrollment Unit P.O. Box 1461 Columbus, Ohio 43216-1461 1-800-686-1516 Monday through Friday, 8:00 am to 4:30 pm

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