Revision : 1
Record Description : Provider applications and registration of those physicians, pharmacists, dentists, ambulatory services, medical suppliers, and nonprofit organizations which provide services to Medicaid recipients. Files may contain additional information reflecting changes in provider rates, staffing, services, ownership, or organizations which may affect the provider’s status. Organized by provider number, the file may include, but is not limited to, license and certification credentials; any or all of the following application, change and verification forms T125, ODHS 6750, 6751, 6752 and 6777; and copies of MMIS screen data listing the provider name and address, license, application date, recertification date, service codes and data entry operator identifier.