Provider Application

If you are a provider interested in joining Oklahoma Health Network, please complete the Provider Application provided below.


Click here if you would like to download and fax the Provider Application form to 405-353-7068 instead of submitting it below.

Provider's Information

* Required Field below
First Name *  
Middle Name
Last Name *  
Professional Degree  
Primary Specialty *  
Subspecialty  
Secondary Specialty  
Subspecialty  
OK License Number  
Tax ID No. *  
NPI *  
Medicare No.  

Office Address

Street *  
Suite  
City *  
State *  
Zip Code *  
Phone *  (999)999-9999
Fax  (999)999-9999
E-mail  

Billing Address

(if different)
Street  
Suite  
City  
State  
Zip Code  
Phone  (999)999-9999
Fax  (999)999-9999
E-mail  

Mailing Address

(if different)
Street  
Suite  
City  
State  
Zip Code  

Other Information

Office Manager  
   
Clinic/Group Name  
Please list all facilities where you have admitting privileges:
Primary Facility  
Other  
Secondary Facility  
Other  
Do you admit patients through a hospitalist?
If yes, please provider the following information.
Hospitalist Name (Primary)  
Hospital  
Hospitalist Name (Secondary)  
Hospital  
Do you have ownership in a facility to which you refer patients?
If yes, please list facilities.
Provider Relations & Customer Service
(405) 440-8835 Oklahoma City
(800) 816-5356 Statewide
(405) 353-7068 Fax
Email Us
Oklahoma Health Network
4013 N.W. Expressway
Suite 575
Oklahoma City, OK 73116