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

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 a Role (Select one)

Contract Billing Company Information

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