Individual Practitioners Documents

• Enrollment Application *
• IRS W-9 *
• 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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