Provider Connection Registration Form

Provider Connection is a secure environment for physicians and practice staff to access OhioHealthy transactions. Please complete the registration form below for each Provider Connection user; username and password information is confidential and should not be shared.

After the registration has been submitted and processed, the user will receive a secure email with a username and temporary password. Upon successful sign in to Provider Connection users will have instant access to member eligibility, benefits, and claim information; access to remits will be available the day after the email is received.

If you have any questions, please contact OhioHealthy Provider Services.


Acceptance Agreement

I acknowledge that the user below is an authorized representative of this practice/facility. I agree to notify OhioHealthy promptly of additions or deletions of users by requesting an "Account Change" on this form. I understand that with the implementation of on-line health plan information, our practice will receive information from OhioHealthy electronically, instead of by mail and/or fax.


Introductory Information

*An asterisk denotes required information

Type of Request*:

If Account Change please describe type of change:


Is this a Practice or Billing Company? Check one.*



User Information

   

Practice or Billing Company Demographic Information

Please list any additional Tax ID numbers for all practices for which you are requesting access.


Role Information (Select one)








Contract Billing Company Information

Contract Billing Company ONLY: This section applies only if you are a billing company contracted by the physician practice. List the name of all practice(s) for which you provide billing services.

If Contract Billing Company, do you require access to Patient Clinical Data?

If Contract Billing Company, has a Business Associate Agreement between your company and the provider office(s) you represent been filed with OhioHealthy.


Practice Supervisor