New EHR Account Information

Name(Required)

First Middle Last

Phone(Required)

NPI #

If not known, please contact us

Medicaid #

If not known, please contact us

Ohio License or Certification #

CAQH #

If not known, please contact us

DEA # (MD/DO/NP/PA's only)

XDEA # (MD/DO/NP/PA's only)

Medical Designation (Please choose one)

Highest Level of Education

Please be specific

MD/DO/NP/PA: Please list area of specialty

Family practice, emergency medicine, etc

Ohio Licensure

Start/Effective Date

End/Expiration Date

Medicaid Application

Per the Medicaid Behavioral Health Redesign rule establish in 2018; ALL Providers must have a Medicaid Number to participate in their program. Without this, We are not able to bill for any Counseling, Nursing, or Provider services that you will be providing. You will carry this number with you for the rest of your career. Here is the information needed to complete the application for enrollment:

Name

First Middle Last

NPI #

Ohio License or Certification #

Board that issues your License/Certification

SS#

DOB

Country of Birth

City of Birth

State of Birth

Have you ever been issues an Ohio Medicaid number

Yes

If YES, please provide #

Have you ever been convicted of a state or federal crime?

Yes

If YES, please provide Date of Incident, Charge(s), Outcome (dismissed, convicted, jailed, etc)

Have you ever been sanctioned by Ohio Medicare or Ohio Medicaid?

Yes

Signature

By signing below, you are allowing KAV Health Group to complete your Medicaid application on your behalf and are attesting that the aforementioned information is accurate to the best of your knowledge.