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Fill Out Your Standardized Department Insurance Form

The Standardized Department Insurance Form is a specific application used by facilities seeking credentialing to ensure they meet necessary requirements for participation in health networks. This comprehensive form allows providers to showcase detailed information about their organization, including licensing, services, and staffing. For those ready to begin this process, please fill out the form by clicking the button below.

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Fill Out Your Standardized Department Insurance Form

Article Structure

The Standardized Department Insurance (SDI) form serves as a critical tool for agencies, programs, and organizations seeking to engage with health plans and networks effectively. This comprehensive application requires detailed and meticulous information to ensure that providers meet the necessary criteria for participation. Each section must be completed thoroughly, with no blank spaces, and applicants are instructed to specify any information that is not applicable. The form includes a checklist for vital documents such as state licenses, insurance certificates, and accreditation letters, guiding applicants in compiling the required paperwork. It's essential to note that separate forms may be needed for different practice locations or provider types, which can streamline the credentialing process. Key aspects of the form encompass provider identification details, practice information, billing specifics, and insurance coverage information. Notably, the form should be submitted directly to health plans rather than the Ohio Department of Insurance, as the latter does not utilize it for reporting purposes. Ensuring that all components of the form are completed accurately can facilitate a smoother path to maintaining compliance and securing necessary certifications in the health services landscape.

Standardized Department Insurance Example

Mike DeWine, Governor	Judith L. French, Director
Jon Husted, Lt Governor

Standardized Credentialing Form Part B: Agency/Program/Organization Providers

Product Regulation Division, 50 W Town Street, 3rd Floor - Suite 300, Columbus OH 43215

614-644-2661 | 614-644-5238 FAX | insurance.ohio.gov

Please complete each section leaving no blank spaces. Clearly state if information requested is not applicable or not available and why. Attach additional sheets when necessary. Separate forms may be required for each National Provider Identifier (NPI), practice location, and provider type.

You must include copies of the following documents, as applicable, with this completed application. Use this checklist as a guide:

State License

Local Business License

Registrations or Certifications

DEA and/or CDS Certificate

CLIA Certificate

Terminal Distributor License

Current Certificate of General Liability Insurance

Current Certificate of Professional Liability Insurance

Form W-9

Workers’ Compensation Certificate of Coverage

Accreditation Letter and Certificate

Medicare Certification Letter

Medicaid Certification Letter

If the Provider is not accredited, please include the following information:

C.V. of Medical Director	N/A
C.V. of Clinical Director	N/A
Credentialing Plan	N/A
Most recent CMS or State Surveys, Correction Action Plans and Revisit Reports	N/A
Documented staff attendance at OSHA Training	N/A
Documented compliance with OSHA record keeping rules regarding workplace injuries and illness	N/A
Confidentiality Plan	N/A

Note: Please submit this form directly to health plans and other entities that credential facility providers for participation in their networks. DO NOT send this form to the Ohio Department of Insurance; the Department does not use the form for any reporting purposes.

INS5036 (Rev. 02/2021)

Page 1 of 8

Ohio Department of InsuranceStandardized Credentialing Form Part B: Agency/Program/Organization Providers

Provider Identification

Legal Name of Applicant:						Federal Tax Identification Number:

Doing Business As (DBA):

Type of Provider:						NPI:

Primary Office Address:

Mailing Address (if different from business address):					City:		State:	Zip Code:

Date and State of Incorporation or Registration:

List all other states in which applicant is approved to conduct external reviews:						Length of time in business with this
						legal name and Tax ID:
Credentialing Contact Name:			Year Applicant Opened:

Address (If different from above):

Phone:		Fax:		Email:

Applicant Owner/Parent Company:

Type of Entity	Corporation	Partnership			Limited Liability Company
(Check one)	Joint Venture	Other:
List all memberships in professional organizations and trade associations:

		Medical Director
Name (Last, First, Middle):

Degree:			Specialty:

Office Address:

Phone:	Fax:			Email:

No Medical Director

INS5036 (Rev. 02/2021)

Page 2 of 8

Ohio Department of InsuranceStandardized Credentialing Form Part B: Agency/Program/Organization Providers

Provider Practice Information

Name:

Street Address/PO Box:

City:

State:

Zip Code:

Phone:

Fax:

Email:

Website:

Primary Contact Name and Title:

Phone:

Fax:

Email:

Hours of

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Operation:

Included in Provider

Directory?

List language

and sign language

interpreters/ contractors:

Is teletype available?

Yes

Federal Tax ID number:

NPI:

Administrator/ Site Manager:

Service Areas (Counties):

Handicapped Access:

On Bus Route:

Number of Beds:

Yes

Additional Practice Location

Name:

Street Address/PO Box:

City:

State:

Zip Code:

Phone:

Fax:

Email:

Website:

Primary Contact Name and Title:

Phone:

Fax:

Email:

Hours of

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Operation:

Included in Provider

Directory?

List language

and sign language

interpreters/ contractors:

Is teletype available?

Yes

Federal Tax ID number:

NPI:

Administrator/ Site Manager:

Service Areas (Counties):

Handicapped Access:

On Bus Route:

Number of Beds:

Yes

INS5036 (Rev. 02/2021)

Page 3 of 8

Ohio Department of InsuranceStandardized Credentialing Form Part B: Agency/Program/Organization Providers

Additional Practice Location

Name:

Street Address/PO Box:

City:

State:

Zip Code:

Phone:

Fax:

Email:

Website:

Primary Contact Name and Title:

Phone:

Fax:

Email:

Hours of

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Operation:

Included in Provider

Directory?

List language

and sign language

interpreters/ contractors:

Is teletype available?

Yes

Federal Tax ID number:

NPI:

Administrator/ Site Manager:

Service Areas (Counties):

Handicapped Access:

On Bus Route:

Number of Beds:

Yes

Billing Information

To whom shall checks be made payable:

Billing Address (Street/PO Box):

City:

State:

Zip Code:

Phone:

Fax:

Email:

Type of Claim Form Used:

CMS1500

UB04

UB92

Other

Accreditation Status

Accrediting Agency Name:

Accreditation Status:

Accreditation Date:

Have you ever been denied accreditation by any accrediting body?

Yes

If yes, please provide details:

Licensure and Certifications

Medicaid Provider Number and Status:

Medicare Provider Number and Status:

License Number and Status:

CLIA Number:

INS5036 (Rev. 02/2021)

Page 4 of 8

Ohio Department of InsuranceStandardized Credentialing Form Part B: Agency/Program/Organization Providers

Scope of Services

List all services offered (attach separate page if necessary):

Does the Provider have a toll free number?	Yes	No
If Yes, please provide number:


Is the Provider staffed 24 hours a day?	Yes	No
Is the Provider part of a national network of providers?	Yes	No
If Yes, please describe:


Does the Provider accept Worker’s Compensation patients?	Yes	No
What is the accepted age range of the Provider’s patients?


Does the Provider subcontract with other Providers?	Yes	No
If Yes, please provide names, addresses, description of services provided, and a copy of each contract:

Liability Insurance

General Liability Coverage (Attach certificate showing current coverage amounts and effective dates)

Name of Carrier:			Policy Number:

Street Address/PO Box:

City:			State:	Zip Code:

Coverage Type:	Occurrence Based	Claims Based

Effective Date:			Expiration Date:

Per Incident:			Aggregate:
$			$
		Professional Liability (Malpractice) Coverage
Name of Carrier:			Policy Number:

Street Address/ PO Box:

City:			State:	Zip Code:

Coverage Type:	Occurrence Based	Claims Based

Effective Date:			Expiration Date:

Per Incident:			Aggregate:
$			$

Staffing

Provide a list of the types, numbers of professional disciplines, licensures and/or certifications represented on the staff. Provide a list of any special certifications, accreditations, or licensures held by the professional staff of your organization.

INS5036 (Rev. 02/2021)

Page 5 of 8

Ohio Department of InsuranceStandardized Credentialing Form Part B: Agency/Program/Organization Providers

Electronic Capabilities

What are the Provider’s current electronic capabilities?

What billing and documentation software is the Provider currently using?				What version is the software?

Does the Provider use this to perform eligibility verification?				Sent in groups (Batch)?
Yes	No		Or one at a time (Real Time)?
Does the Provider use this to perform electronic claim submissions?			Sent in groups (Batch)?
Yes	No		Or one at a time (Real Time)?
Does the Provider use Electronic Medical Records (EMR)?		What is the name of the EMR software?
Yes	No
What version is the EMR?		Is the EMR software compatible with your billing and
		documentation software?			Yes	No

Disclosure Questions

Please answer the following questions by checking the appropriate box. If the answer to any question is yes, please provide a

complete description of the facts on a separate attached sheet.
Have criminal proceedings ever been initiated against the Provider or its authorized representatives?	Yes	No
Has the Provider ever been the subject of an investigation or ever been terminated, suspended, sanctioned or	Yes	No
otherwise restricted from participating in any private or public program including, but not limited to,
Medicare, Medicaid and military or Department of Health programs?
Has the Provider’s professional liability coverage ever been restricted, limited, denied, not renewed, or special	Yes	No
rated for any reasons other than the carrier’s termination of operations in your State?
Has the Provider ever been notified that information pertaining to anyone in the Provider’s staff has been	Yes	No
reported to the National Practitioner Data Bank, Healthcare Integrity and Protection Data Bank or
professional state licensing boards or registries?
In the last five years, have there been any professional liability suits, or are there currently any pending or	Yes	No
threatened suits against the Provider, or have any judgments been made or settlements paid on its behalf?
Is there currently any pending or threatened licensing or disciplinary action against the Provider?	Yes	No

References

Please provide at least three references from Healthcare Providers, Organizations, or Managed Care Organizations that the Provider currently services.

Name:	Company:

Address:	Phone:

Name:	Company:

Address:	Phone:

Name:	Company:

Address:	Phone:

INS5036 (Rev. 02/2021)

Page 6 of 8

Ohio Department of InsuranceStandardized Credentialing Form Part B: Agency/Program/Organization Providers

Standard Authorization, Attestation and Release

I am the authorized agent of the Applicant named below and have the authority to execute this document on behalf of the Applicant. I understand that as part of the credentialing application process to participate as a Provider (hereinafter, referred to as "Participation") with _________________________________________(insert name of Contracting Entity), all Applicants are required to provide

sufficient and accurate information for the proper evaluation of all criteria used by the Contracting Entity for determining initial and ongoing eligibility for Participation. I acknowledge and understand that my cooperation in obtaining information in connection with this application and my consent to the release of information does not guarantee that the Contracting Entity will contract with the Applicant as a provider of services.

Authorization of Investigation Concerning Application for Participation.

The following individuals including, without limitation, the Contracting Entity, its representatives, employees, and/or designated agent(s); the Contracting Entity's affiliated entities and their representatives, employees, and/or designated agents; and the Contracting Entity's designated professional credentials verification organization (collectively referred to as "Agents"), are hereby authorized to investigate information, which includes both oral and written statements, records, and documents, concerning this application for Participation. The Applicant agrees to allow the Contracting Entity and/or its Agent(s) to inspect and copy all records and documents relating to such an investigation.

Authorization of Third-Party Sources to Release Information Concerning Application for Participation.

The Applicant hereby authorizes any third party, including, but not limited to, individuals, agencies, medical groups responsible for credentials verification, corporations, companies, employers, former employers, hospitals, health plans, health maintenance organizations, managed care organizations, law enforcement or licensing agencies, insurance companies, educational and other institutions, military services, medical credentialing and accreditation agencies, professional medical societies, the Federation of State Medical Boards, the National Practitioner Data Bank, and the Health Care Integrity and Protection Data Bank, to release to the Contracting Entity and/or its Agent(s), information, including otherwise privileged or confidential information, concerning the qualifications of this Applicant, its credentials, accreditations, quality assurance and utilization data, or any other information reasonably having a bearing on the Applicant’s qualifications for Participation with the Contracting Entity. This information shall also include the details of any action taken by a health care organization, Medicare and Medicaid, their administrators or their medical or other committees to revoke, deny, suspend, restrict, or condition the Applicant’s Participation, impose a corrective action plan or terminate any contract to which the Applicant was a party. The Applicant further authorizes its current and past insurance carrier(s) to release this Applicant’s history of claims that have been made and/or are currently pending against it. The Applicant specifically waives written notice from any entities and individuals who provide information based upon this Authorization, Attestation and Release.

Release from Liability.

The Applicant hereby releases from all liability and holds harmless any Contracting Entity, its Agent(s), and any other third party for their acts performed in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of the Contracting Entity, its Agent(s), or other third party in connection with the gathering, release and exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release. The Applicant further agrees not to sue any entity, any agent(s), or any other third party for their acts, defamation or any other claims based on statements made in good faith and without malice or misconduct in connection with the credentialing process. This release shall be in addition to, and in no way shall limit, any other applicable immunities provided by law for credentialing activities.

In this Authorization, Attestation and Release, all references to the Contracting Entity, its Agent(s), and/or other third party include their respective employees, directors, officers, advisors, counsel, and agents. The Contracting Entity and its affiliates or agents retain the right to allow access to the application information for purposes of a credentialing audit to customers and/or their auditors to the extent required in connection with an audit of the credentialing processes and provided that the customer and/or their auditor executes an appropriate confidentiality agreement.

The Applicant understands and agrees that this Authorization, Attestation and Release is irrevocable for any period during which the entity identified below is an Applicant or a Provider with the Contracting Entity. The Applicant agrees that it shall execute another form of consent if any law or regulation limits the application of this irrevocable authorization. The Applicant understands that its failure to promptly provide another form of consent may be grounds for termination or discipline by the Contracting Entity in accordance with the applicable bylaws, rules, and regulations, and requirements of the Contracting Entity, or grounds for its termination of Participation with the Contracting Entity.

INS5036 (Rev. 02/2021)

Page 7 of 8

Ohio Department of Insurance	Standardized Credentialing Form Part B: Agency/Program/Organization Providers

Standard Authorization, Attestation and Release (continued)

The undersigned certifies that all information provided in its application is current, true, correct, accurate and complete to the best of his/her knowledge and belief, and is furnished in good faith. The Applicant will notify the Contracting Entity and/or its Agent(s) within ten (10) days of any material changes to the information (including any changes/challenges to licenses, DEA, insurance, malpractice claims, NPDB/HIPDB reports, discipline, criminal convictions, etc.) that has been provided in its application and /or is authorized to be released pursuant to the credentialing process. The Applicant understands that corrections to the application are permitted at any time prior to a determination of Participation by the Entity, and must be submitted online or in writing, and must be dated and signed by an authorized agent of the Applicant (may be a written or an electronic signature). The Applicant acknowledges that it is responsible to provide a complete application and to produce adequate and timely information for resolving questions that arise in the application process. The Applicant understands and agrees that any material misstatement or omission in the application may constitute grounds for withdrawal of the application from consideration; denial or revocation of Participation; and/or immediate suspension or termination of Participation. This action may be disclosed to the Contracting Entity and/or its Agent(s).

The undersigned acknowledges that he/she has read and understands the foregoing Authorization, Attestation and Release. A facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.

Signature (Do not stamp)		Name (print)

Date		Title (Print)

		Name of Applicant (Print)

INS5036 (Rev. 02/2021)

Page 8 of 8

Get Standardized Department Insurance PDF Form

Form Characteristics

Fact Name	Description
Governing Authority	The Standardized Department Insurance form is governed by Ohio Revised Code 1751.60.
Applicant Requirements	Applicants must complete all sections, ensuring no blank spaces, and clearly indicate any non-applicable information.
Document Submission	Attachments like state licenses and liability insurance certificates are required along with the completed form.
Submission Instructions	This form should be submitted directly to health plans; it is not used by the Ohio Department of Insurance for reporting.

Guidelines on Utilizing Standardized Department Insurance

Filling out the Standardized Department Insurance form requires careful attention to detail, as every section must be completed accurately. This ensures that your application is processed without delay. Before you start, gather all necessary documents and information to facilitate a smooth completion of the form. Below are the steps to guide you through the process.

Begin with the Provider Identification section. Fill in the legal name of the applicant, the Federal Tax Identification Number, and if applicable, the Doing Business As (DBA) name.
Provide the type of provider and enter the National Provider Identifier (NPI) number. Complete the primary office address, including city, state, and zip code. If you have a different mailing address, make sure to include that as well.
Document the date and state of incorporation or registration. List all other states in which your organization is approved to conduct external reviews.
Indicate the length of time your entity has been in business under the legal name and Tax ID. Complete the credentialing contact information, including name, address, phone, fax, and email.
Identify the applicant's owner or parent company, and specify the type of entity, such as corporation or partnership.
List all memberships in professional organizations and trade associations.
Provide details about the Medical Director, including name, degree, specialty, office address, and contact information. If no Medical Director is appointed, clearly state that.
Next, fill in the Provider Practice Information. Include the name, address, phone, fax, email, website, and primary contact information for your practice.
Address operating hours for each day of the week. Indicate if you will be included in the provider directory and list any interpreters or contractors available.
Answer whether teletype is available and provide the Federal Tax ID number and NPI for the practice.
If applicable, complete details about additional practice locations.
In the Billing Information section, state to whom checks should be made payable. Include the billing address and type of claim form you use.
Fill in information related to Accreditation Status, including the accrediting agency name and status.
Document any licensure and certification details, such as Medicaid Provider Number, Medicare Provider Number, and license status.
In the Scope of Services section, list all services offered and whether you have a toll-free number. Specify if services are available 24/7 and if you are part of a national network.
Complete the Liability Insurance section. Provide details for your general and professional liability coverage, including policy number, coverage type, effective date, and coverage amounts.
Lastly, include staffing information by listing the types of professional disciplines and any special certifications held by your staff.

Make sure to review your form thoroughly before submission to ensure that all information is accurate and complete. Attach any required documentation and send the form directly to the relevant health plans and credentialing entities. Remember, do not send this form to the Ohio Department of Insurance.

What You Should Know About This Form

What is the purpose of the Standardized Department Insurance form?

The Standardized Department Insurance form is used by providers to submit essential documentation needed for credentialing. It collects important information about the agency, program, or organization, enabling health plans and other entities to evaluate providers for participation in their networks. Ensuring accurate and complete information helps facilitate a smoother credentialing process.

Who is required to fill out this form?

Any agency, program, or organization that seeks to provide services and wants to be credentialed by health plans must complete this form. This includes those with National Provider Identifiers (NPIs) and varying practice locations. It's important for each separate entity to submit its own form, ensuring a comprehensive overview of its qualifications and services.

What documents must be included with this application?

Along with the completed form, several documents must be attached, depending on the provider’s specifics. Required documents may include state licenses, certifications, liability insurance certificates, and any relevant Medicare or Medicaid certifications. A checklist is provided within the form to guide applicants through the necessary documentation, making it easier to understand what is required.

Can I submit the form to the Ohio Department of Insurance?

No, you should not submit this form to the Ohio Department of Insurance. The Department does not utilize this form for reporting purposes. Instead, the form must be sent directly to the appropriate health plans or entities that are responsible for credentialing providers.

What should I do if a section of the form is not applicable to my organization?

If a specific section of the form is not applicable, you should clearly indicate this in the designated area. It's essential to provide an explanation as to why that information is not available or relevant to avoid any confusion during the credentialing review process.

What if I need more space to provide information or documentation?

You may attach additional sheets if necessary. Make sure each attachment is labeled clearly, referencing the section of the form it pertains to. Providing supplementary details helps ensure that your application is complete and offers a full picture of your organization’s credentials and capabilities.

Common mistakes

Filling out the Standardized Department Insurance form requires attention to detail. One common mistake is leaving blank spaces instead of indicating when information is not applicable. Each section must be completed, and if something does not apply, clearly mark it as such. Failure to do this can lead to delays in processing the application.

Another common error is neglecting to attach required documents. The form specifies numerous important documents, such as state licenses and certifications. If these are not included, the application risks being denied or returned. It's essential to check off each item on the checklist provided in the instructions to ensure completeness.

Using outdated information is also a frequent mistake. Applicants often fill out sections with old addresses, licenses, or contact numbers. Verification of all details, especially the Federal Tax Identification Number and the National Provider Identifier (NPI), is crucial for accurate processing of the form.

Avoid confusion by not assuming prior applications have the same requirements. Each application may have unique needs based on current regulations or changes in requirements. Applicants should carefully read the form's instructions to confirm all sections are relevant and accounted for.

Additionally, some applicants mistakenly submit the form to the Ohio Department of Insurance, contrary to the instructions. This form is not intended for submission to the Department. Instead, it must be sent directly to health plans and credentialing entities. Missteps in addressing submission can cause significant delays or complications.

Lastly, failing to provide clear and up-to-date contact information can hinder communication. Each section involving contact details should be double-checked for accuracy. In the event any clarification is needed, the credentialing body must easily be able to reach the applicant.

Documents used along the form

When completing the Standardized Department Insurance form, you may also need to gather additional documentation. Each of these documents plays a crucial role in your application process. Here is a list of common forms and documents often required alongside the Standardized Department Insurance form.

State License: This document confirms your authorization to operate in your state. It is essential for compliance with state regulations.
Local Business License: Required for local compliance, this license indicates that your business meets city or county regulations.
Registrations or Certifications: Different industries have specific registrations or certifications that you must hold to operate legally.
DEA and/or CDS Certificate: These permits are necessary for handling controlled substances, indicating compliance with federal regulations.
CLIA Certificate: This certificate is important for laboratories performing certain tests, ensuring they meet federal standards.
Current Certificate of General Liability Insurance: This document shows that you have liability coverage, protecting against claims of injury or damage.
Current Certificate of Professional Liability Insurance: Also known as malpractice insurance, it protects against claims of negligence in professional services.
Form W-9: This form is used to provide your Tax Identification Number (TIN) to clients or businesses required to report payments made to you.
Workers’ Compensation Certificate of Coverage: This certificate proves that you have workers’ compensation insurance to cover employee injuries.

Gathering these documents will help streamline your application process and ensure that you meet all necessary requirements. Being prepared will make a positive impact on your overall compliance and operational readiness.

Similar forms

Credentialing Application Forms: Similar to the Standardized Department Insurance form, these documents collect essential information about healthcare providers to ensure they meet the necessary qualifications and standards. They typically ask for detailed information about the provider's licenses, certifications, and practice history.
Provider Enrollment Forms: These forms are used by providers to enroll in insurance networks or Medicaid programs. Like the Standardized form, they require extensive background information, including licensing details and proof of insurance.
Licensure Applications: Licensure applications serve the purpose of granting healthcare professionals the authority to practice in a specific state. Similar to the Standardized form, they often require documentation of education, training, and proof of examination.
Accreditation Applications: Accreditation bodies require detailed applications to assess whether healthcare organizations meet industry standards. These applications echo the Standardized form's focus on compliance with regulations, submission of documentation, and ongoing accountability.
Insurance Policy Documents: Provider liability insurance forms and general coverage documents outline the scope of coverage and stipulations for claims. These documents often need to accompany credentialing applications to validate that providers have appropriate liability coverage.
Quality Improvement Plans: Similar in intent, these plans address how a provider will maintain or enhance the quality of services delivered. They might contain information about staff training and adherence to safety standards, much like the Standardized form requires compliance documentation.

Dos and Don'ts

When filling out the Standardized Department Insurance form, here's what you should do:

Complete every section of the form without leaving blank spaces.
Clearly indicate if certain information is not applicable and explain why.
Attach any additional sheets if required.
Include all necessary documents, such as licenses and insurance certificates.
Submit the form directly to the relevant health plans, not the Ohio Department of Insurance.

Also, avoid these common mistakes:

Do not send the form to the Ohio Department of Insurance.
Do not skip over sections, even if they seem irrelevant.
Do not use outdated information or documents.
Do not forget to provide a valid email and phone number for contact.
Do not assume that separate forms are unnecessary for different NPIs or locations.

Misconceptions

Misconceptions about the Standardized Department Insurance form can lead to confusion and delays in the credentialing process. Here are some of the most common misconceptions, along with clarifications for each.

All providers can use the same form. Each provider may need a separate form for different National Provider Identifiers (NPIs) or provider types, which varies by practice location.
The form needs to be sent to the Ohio Department of Insurance. This is incorrect; the form should be submitted directly to health plans and entities that credential providers.
Blank spaces on the form are acceptable. Every section of the form must be completed. If particular information does not apply, applicants are required to indicate so and provide an explanation.
A single checklist is sufficient for all submissions. Although a checklist is provided, some documents may differ based on the specific requirements of the recipient entity.
Only accredited providers need to submit additional information. Non-accredited providers must also provide detailed information, such as a Credentialing Plan and documentation of OSHA training.
The form is only about insurance details. In addition to insurance, the form requires comprehensive information about the provider’s practice, staffing, and services offered.
Submitting the form guarantees automatic approval. Completion of the form does not guarantee credentialing approval; each submission will be subject to review by the respective health plan or entity.
All information provided will be kept confidential. While many aspects may be confidential, certain details, especially those related to licensure and accreditation, could be subject to public disclosure under transparency laws.

Key takeaways

When filling out and using the Standardized Department Insurance form, attention to detail is crucial. The following takeaways offer insights into key aspects of the process.

All sections of the form must be completed. Leaving blank spaces will delay processing.
Clearly indicate when certain information is not applicable. Providing an explanation is recommended.
Multiple forms may be needed for different National Provider Identifiers (NPIs) or practice locations.
A checklist of required documents accompanies the form. Ensure all appropriate documents are included with the submission.
Do not send the completed form to the Ohio Department of Insurance, as it is not used for reporting.
Accredited providers must include a variety of supplemental documents. Non-accredited ones have additional requirements to fulfill.
It is advisable to submit the form directly to health plans that credential facility providers.
The information provided on the form must be accurate and up-to-date to avoid complications in the credentialing process.

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