If you are a provider interested in joining Oklahoma Health Network, please complete the Provider Application provided below. If you are currently a contracted provider wishing to update or change your provider information, please complete the relevant sections on the Provider Application.
Click here to download and fax the Provider Application form.
First Name  
Middle Name
Last Name  
Professional Degree  
Primary Specialty  
Subspecialty  
Secondary Specialty  
Subspecialty  
OK License Number  
Tax ID No.  
Medicare No.  
Office Address
Street  
Suite  
City  
State  
Zip Code  
Phone  
Fax  
E-mail  
Billing Address (if different)
Street  
Suite  
City  
State  
Zip Code  
Phone  
Fax  
E-mail  
Mailing Address (if different)
Street  
Suite  
City  
State  
Zip Code  
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.


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