Provider Forms


Please download the desired form, type in the required information, then email the completed form to OHCProviderRelations@OhioHealthChoice.com. If you are unable to complete online and email, you can choose to submit the form using one of the alternative methods listed on the form.

Name Description
Interested Practitioner Form Use this if you are an interested individual practitioner wishing to request to join the Ohio Health Choice network. Download
Interested Facility Form Use this if you are an interested facilty wishing to request to join the Ohio Health Choice network. Download
Provider Demographic Change Form Use this to communicate a change to your demographics, such as an address or Tax ID change. Download
Request CPT Reimbursement Amount Form Use this form to submit up to 15 of your most common CPT codes to determine your reimbursement amount from Ohio Health Choice. Download