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Provider Forms


Contracts and applications

Each contract below contains the appropriate application and a list of the required attachments. Complete the application by entering the required information in the open fields and sign electronically or digitally. Completing and signing electronically makes them easier to read, which results in fewer mistakes, questions and delays in processing your application. You can then email the contract, application and attachments to EGID.NetworkManagement@omes.ok.gov. If you do need to print the application, it can be faxed to 405-717-8977.

In lieu of the application, EGID will accept the Uniform Credentialing Application for the state of practice or a profile from CAQH.

Forms

NOTICE: Non-network providers
Do not use the network provider forms to add a location or change your practice information. Please call the claims administrator directly at 800-323-4314. TTY users call 711. The forms are for network providers only.

Change Form
The Change Form is required when changing a service address, mailing address, tax ID number or contact information. You must include the previous address or tax ID number and an effective date of the change. The entire form must be completed as failure to do so could result in non-network payments.

Additional Location Form
The Additional Location Form is required when adding another office location under a contracted tax ID number.

Last Modified on Jan 08, 2021