Step 1 of 6

Personal Information

Your Full Legal Name(Required)

First Middle Last

Type of therapy

Physical Therapy (PT)

Occupational Therapy (OT)

Speech Therapy (ST)

Have you ever gone by any other name?

Yes

SSN(Required)

Upload Driver's License or State Issued ID:

Max. file size: 512 MB.

Date of Birth:(Required)

Place of Birth (City, State/Province, Country)(Required)

Are you a citizen of the United States?

Yes

List any languages you speak other than English:

Practice Information

Name of Group:

Website

Primary Specialty:

Secondary Specialty:

Ages you treat:

Gender Limitations:

None

Male Only

Female Only

Other

Credentials

NPI: Type 1:

**NPI Username:

NPI Password:

(See notes)

Individual Medicare number:

Individual Medicaid number:

Do you have Medicaid outside of Oklahoma?(Required)

Yes

OHCA Username:

OHCA Password:

Board Certification number:

Certification Date:

Upload Certificate:

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 12 MB.

State License Number:

Licensing State:

Upload License

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 12 MB.

2nd State License Number:

2nd Licensing State:

Upload 2nd License

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 12 MB.

3rd State License Number:

3rd Licensing State:

Upload 3rd License

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 12 MB.

CAQH Info:

CAQH number:

**CAQH Username:

CAQH Password:

If you do not have this, you will need to call CAQH and request it. The number is 888-599-1771.

PT / OT / ST New Provider Application

PT - OT - ST New Provider Application - Step 1

Personal Information

Practice Information

Credentials

Insurance

Practice Location Details

Contact Info

If you have questions about the on-boarding, please contact our office at 405-849-4016. We are happy to help!