INTERESTED PRACTITIONER REQUEST Thank you for your interest in becoming a provider with Ohio Health Choice. Please take a few minutes to complete and return the below form in order to evaluate our provider needs in your area. Written requests to join the OHC network must be submitted by the practitioner. All requests are reviewed by the OHC Network Committee on a monthly basis. Practitioners will be notified via US Mail of the decision. Submission of a letter of interest does not guarantee acceptance into the OHC networks. NOTE: ODI’s and/or NPDB’s are not to be submitted. Submit your written request to: Ohio Health Choice PO Box 2090 Akron, Ohio 44309-2090 Or FAX to: 330-996-8201 INTERESTED PRACTITIONER REQUEST FORM PLEASE NOTE: Effective 1/1/07 Ohio Health Choice will no longer accept certain physician extendors into our provider network. These physicians’ services can be billed under the supervisory physician’s name. This will not affect any provider types that are currently in the Ohio Health Choice network. The specialties that will no longer be accepted are: -Clinical Chemical Dependency Counselor -Licensed Independent Chemical Dependency Counselor -Certified Registered Nurse Anesthetist -Certified Nurse Midwife -Certified Nurse Practitioner -Licensed Certified Social worker -Licensed Professional Counselor -Licensed Social Worker -Occupational Therapists -Registered Dieticians -Registered Nurses -Physician Assistants Effective 9/1/2007, all new physical therapists must be a part of the Ohio Physical Therapy Network to join the OHC network. If you are currently in the network, you will be grandfathered in. OPTN's number is 800-636-6786. Their fax is 614-457-1564. Please call our office at 800-554-0027 if you have additional questions. © Copyright 2008 Ohio Health Choice