Common use of REQUIRED ATTACHMENTS Clause in Contracts

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoice. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Accreditation (if applicable) Incomplete applications will be returned. Network Facility Application The completed Network Facility Application should be returned to the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office of Management and Enterprise Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 Oklahoma City, OK 73112 Phone: 000-000-0000 or 000-000-0000 Fax: 000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility Contacts

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoice. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Accreditation (if applicable) Incomplete applications will be returned. Network Facility Application The completed Network Facility Application should be returned to the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office of Management and Enterprise Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 Oklahoma City, OK 73112 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility Contacts

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoice. ☐ Contract Signature Page ☐ Electronic Funds Transfer (EFT) Form ☐ Copy of voided check or bank letter for Electronic Funds Transfers ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Joint Commission Accreditation Certificate (if applicable) ☐ Copy of AAAHC Accreditation Certificate (if applicable) Incomplete applications will be returned. Network Facility Application The completed Network Facility Application should be returned to the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office of Management and Enterprise Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 Oklahoma City, OK 73112 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The the Joint Commission: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARFthe AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility Contacts

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoice. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Accreditation (if applicable) Incomplete applications will be returned. Network Facility Application The completed Network Facility Application should be returned to the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office of Management and Enterprise Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 Oklahoma City, OK 73112 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ☐Yes ☐No The Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: _ Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility Contacts

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoice. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Accreditation (if applicable) Incomplete applications will be returned. Network Facility Application The completed Network Facility Application should be returned to the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office of Management and Enterprise Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 Oklahoma City, OK 73112 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Accred itation Is this Facility accredited by The Joint Commission: ☐Yes ☐No The Joint Commission Program ID Number: Date of most current accreditation: Expiration Exp iration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Exp iration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility Contacts

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoiceDepartment of Rehabilitation Services. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF AAAHC Accreditation (if applicable) Incomplete applications Applications will be returned. returned Department of Rehabilitation Services Network Facility Application The completed Network Facility Application should be returned to the Department of Rehabilitation Services at the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office Department of Management and Enterprise Rehabilitation Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 P.O. Box 57630 Oklahoma City, OK 73112 Oklahoma 00000-0000 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet Certificate Face Sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility Contacts

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) license(s)‌ ☐ Face Sheet of current general and medical liability insurance policy policy‌ Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoice. ☐ Contract Signature Page Page‌ ☐ Copy of Medicare Certification Letter Letter‌ ☐ Copy of TJC, AAAHC, or CARF Accreditation (if applicable) applicable)‌ Incomplete applications will be returned. Network Facility Application Application‌‌‌ The completed Network Facility Application should be returned to the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: to:‌ Office of Management and Enterprise Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 Oklahoma City, OK 73112 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information Information‌ State: License Number: Expiration Date: Date:‌ A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No No‌ Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: ‌‌‌‌‌‌ Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration DateDate:‌ CEO/Administrator: Important Telephone Number: Fax Number: Email Address: CFO: ‌‌ Telephone Number: Fax Number: Email Address: Credentialing Contact: Telephone Number: Fax Number: Email Address: ‌‌‌‌‌ Address Information Federal Tax ID Number: National Provider Identification: ‌ Attach a completed W9 form for each Federal Tax ID number. Physical Address – physical location of the Facility ContactsTHIS ADDRESS AND PHONE NUMBER WILL APPEAR ON THE WEBSITE PROVIDER DIRECTORY. Physical Address: ‌‌‌‌ Mailing Address‌ Mailing Address: City State ZIP Phone: Fax: Contact Person: Email Address:‌‌‌ Mailing contact information, if listed, will be utilized for all legal, contractual notices as defined in section 11.2 or 12.2 of the facility contracts. An email address must be included for this contact in order to access the online fee schedules. All notices will be sent electronically. Billing/Remit Address – for claims payments and remittance statements ALL BILLING INFORMATION BELOW MUST MATCH THE INFORMATION REFLECTED ON THE CLAIMS SUBMITTED. Name Submitted on Claims: Billing Office Name (if applicable): Billing Address: City State ZIP Phone: Contact Person: Email Address: Fax: Additional Location‌ Federal Tax ID Number: National Provider Identification: ‌ Attach a completed W9 form for each Federal Tax ID number. Physical Address – physical location of the Facility THIS ADDRESS AND PHONE NUMBER WILL APPEAR ON THE WEBSITE PROVIDER DIRECTORY. Physical Address: Mailing Address- for correspondence/credentialing‌‌‌ Mailing Address: City State ZIP‌ Phone: Fax: Contact Person: Email Address:‌‌‌ Billing/Remit Address – for claims payments and remittance statements ALL BILLING INFORMATION BELOW MUST MATCH THE INFORMATION REFLECTED ON THE CLAIMS SUBMITTED. Name Submitted on Claims: Billing Office Name (if applicable): Billing Address: ‌ City State ZIP Phone: Fax: Contact Person: Email Address:‌‌‌ Please use copies of these pages to report any additional locations. HOSPITAL AND NON-HOSPITAL BASED SERVICES; if applicable Does the Hospital provide the following specialty services? ☐Ambulance ☐Infusion Therapy ☐Ambulatory Surgery Center ☐Laboratory ☐Dialysis ☐Long Term Acute Care ☐Durable Medical Equipment ☐Psych/Substance Abuse ☐Home Health Care ☐Rehabilitation ☐Hospice ☐Skilled Nursing Facility ☐Independent Diagnostic Testing Facility ☐Sleep Study Does the Hospital provide the following services by a group of specialists? If yes, please list the provider group name. ☐Anesthesiology Group: ‌ ☐Emergency Physician Group: ‌ ☐Pathology Group:‌ ☐Radiology Group: ‌ Network Facility Contract Signature Page‌‌‌‌ The Office of Management and Enterprise Services Employees Group Insurance Division (EGID), and the facility incorporate by reference the terms and conditions of the Network Facility Contract into this signature page. EGID and the facility further agree that the effective date of the contract is the effective date denoted on the copy of the executed signature page returned to the facility. The original of the signed document will remain on file in the office of EGID.‌ FOR THE FACILITY: Legal Name of Owner (Typed or Printed) Trade Name/DBA (Typed or Printed) Federal Tax ID Number‌‌ Address of the Facility: Authorized Officer or Representative (Typed or Printed) Title Please return the completed Application, Signature Page, and required attachments to: Office of Management Enterprise Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 Oklahoma City, OK 73112 Phone: 000-000-0000 or 000-000-0000 Fax: 000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx Signature Signature Date FOR EGID: Xxxx X. Xxxx Deputy Administrator Employees Group Insurance Division

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Applicationapplication: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application application which will be used on claim forms submitted to HealthChoice. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Accreditation (if applicable) Incomplete applications will be returned. returned Network Facility Application The completed Network Facility Application should be returned to the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office of Management and Enterprise Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 Oklahoma City, OK 73112 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility Contacts

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoiceDepartment of Corrections. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Accreditation (if applicable) Incomplete applications will be returned. returned Department Of Corrections Network Facility Application The completed Network Facility Application should be returned to the Department of Corrections at the Office of Management and Enterprise Services Employees Group Insurance Division Department in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office Department of Management and Enterprise Services Employees Group Insurance Division Corrections ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 P.O. Box 57630 Oklahoma City, OK 73112 Oklahoma 00000-0000 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ? ☐Yes ☐No The Joint Commission commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility ContactsContacts CEO/Administrator: Telephone Number:

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoiceDepartment of Rehabilitation Services. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHCAAHC, or CARF Accreditation (if applicable) Incomplete applications will be returned. returned Department of Rehabilitation Services Network Facility Application The completed Network Facility Application should be returned to the Department of Rehabilitation Services at the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office Department of Management and Enterprise Rehabilitation Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 P.O. Box 57630 Oklahoma City, OK 73112 Oklahoma 00000-0000 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face Face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility Contacts

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoiceDepartment of Rehabilitation Services. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Accreditation (if applicable) Incomplete applications Applications will be returned. returned Department of Rehabilitation Services Network Facility Application The completed Network Facility Application should be returned to the Department of Rehabilitation Services at the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office Department of Management and Enterprise Rehabilitation Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 P.O. Box 57630 Oklahoma City, OK 73112 Oklahoma 00000-0000 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet Certificate Face Sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility Contacts

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoiceDepartment of Corrections. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Accreditation (if applicable) Incomplete applications will be returned. returned Department Of Corrections Network Facility Application The completed Network Facility Application should be returned to the Department of Corrections at the Office of Management and Enterprise Services Employees Group Insurance Division Department in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office Department of Management and Enterprise Services Employees Group Insurance Division Corrections ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 P.O. Box 57630 Oklahoma City, OK 73112 Oklahoma 00000-0000 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission? The Joint commission Program ID Number: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility ContactsContacts CEO/Administrator: Telephone Number:

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoiceDRS. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Accreditation (if applicable) Incomplete applications will be returned. returned Department of Rehabilitation Services Network Facility Application The completed Network Facility Application should be returned to the Department of Rehabilitation Services at the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office Department of Management and Enterprise Rehabilitation Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 P.O. Box 57630 Oklahoma City, OK 73112 Oklahoma 00000-0000 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility Contacts

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoiceDOC. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Accreditation (if applicable) CLIA Certificate Incomplete applications will be returned. returned Department Of Corrections Network Facility Application The completed Network Facility Application should be returned to the Department of Corrections at the Office of Management and Enterprise Services Employees Group Insurance Division Department in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office Department of Management and Enterprise Services Employees Group Insurance Division Corrections ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 P.O. Box 57630 Oklahoma City, OK 73112 Oklahoma 00000-0000 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ? ☐Yes ☐No The Joint Commission commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility ContactsContacts CEO/Administrator: Telephone Number: Fax Number: Email Address: CFO: Telephone Number: Fax Number: Email Address: Credentialing Contact: Telephone Number: Fax Number: Email Address: Address Information Federal Tax ID Number: Nation Provider Identifier Number: Attach a completed W9 form for each Federal Tax ID number. Physical Address – physical location of the Facility THIS ADDRESS AND PHONE NUMBER WILL APPEAR ON THE WEBSITE PROVIDER DIRECTORY. Physical Address: Mailing Address- for correspondence/credentialing Mailing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Mailing contact information, if listed, will be utilized for all legal, contractual notices as defined in section 11.2 or 12.2 of the facility contracts. An email address must be included for this contact in order to access the online fee schedules. All notices will be sent electronically. Billing/Remit Address – for claims payments and remittance statements ALL BILLING INFORMATION BELOW MUST MATCH THE INFORMATION REFLECTED ON THE CLAIMS SUBMITTED. Name Submitted on Claims: Billing Office Name (if applicable): Billing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Additional Location Federal Tax ID Number: Nation Provider Identifier Number: Attach a completed W9 form for each Federal Tax ID number. Physical Address – physical location of the Facility THIS ADDRESS AND PHONE NUMBER WILL APPEAR ON THE WEBSITE PROVIDER DIRECTORY. Physical Address: Mailing Address- for correspondence/credentialing Mailing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Billing/Remit Address – for claims payments and remittance statements ALL BILLING INFORMATION BELOW MUST MATCH THE INFORMATION REFLECTED ON THE CLAIMS SUBMITTED. Name Submitted on Claims: Billing Office Name (if applicable): Billing Address: City State ZIP Phone: Fax: Contact Person: Email Address: Please use copies of these pages to report any additional locations. Revised 03/13/2018 State of Oklahoma Department of Corrections Laboratory Contract Signature Page When signed by both parties below, this constitutes agreement and acceptance of all terms and conditions contained in the Laboratory Contract. The DOC and the facility further agree that the effective date of the Contract is the effective date denoted on the copy of the executed Signature Page returned to the facility. The original of the signed document will remain on file in the office of the Department. By signing, both parties agree that this document shall become part of the Contract.

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoiceDepartment of Corrections. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHCAAHC, or CARF Accreditation (if applicable) Incomplete applications will be returned. returned Department Of Corrections Network Facility Application The completed Network Facility Application should be returned to the Department of Corrections at the Office of Management and Enterprise Services Employees Group Insurance Division Department in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office Department of Management and Enterprise Services Employees Group Insurance Division Corrections ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 P.O. Box 57630 Oklahoma City, OK 73112 Oklahoma 00000-0000 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ? ☐Yes ☐No The Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility ContactsContacts CEO/Administrator: Telephone Number:

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoice. ☐ Contract Signature Page ☐ Electronic Funds Transfer (EFT) Form ☐ Copy of voided check or bank letter for Electronic Funds Transfers ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHC, or CARF Joint Commission Accreditation Certificate (if applicable) ☐ Copy of AAAHC Accreditation Certificate (if applicable) Incomplete applications will be returned. Network Facility Application The completed Network Facility Application should be returned to the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office of Management and Enterprise Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 Oklahoma City, OK 73112 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The the Joint Commission: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility Contacts

REQUIRED ATTACHMENTS. Please attach a copy of each of the following documents to your completed Application: ☐ Current state(s) license(s) ☐ Face Sheet of current general and medical liability insurance policy Insurance Certificate/Face Sheet must have the name or the Facility listed as the insured. The insurance limits must be at the levels in the Contract and must indicate clearly that it is general and medical liability coverage. ☐ W-9 form for each Federal Tax Identification Number W-9 forms must be signed and list only the Federal Tax Identification Number listed on the Application which will be used on claim forms submitted to HealthChoiceDRS. ☐ Contract Signature Page ☐ Copy of Medicare Certification Letter ☐ Copy of TJC, AAAHCAAHC, or CARF Accreditation (if applicable) Incomplete applications will be returned. returned Department of Rehabilitation Services Network Facility Application The completed Network Facility Application should be returned to the Department of Rehabilitation Services at the Office of Management and Enterprise Services Employees Group Insurance Division in its entirety, accompanied by the applicable attachments. You may mail, fax or email the completed application to: Office Department of Management and Enterprise Rehabilitation Services Employees Group Insurance Division ATTN: Network Management 3545 N.W. 00xx Xx., Xxx. 000 P.O. Box 57630 Oklahoma City, OK 73112 Oklahoma 00000-0000 Phone: 0-000-000-0000 or 0-000-000-0000 Fax: 0-000-000-0000 XXXX.XxxxxxxXxxxxxxxxx@xxxx.xx.xxx General Information Legal Name of Owner: Trade Name/DBA: Medicare Facility Classification: Medicare Number: License Information State: License Number: Expiration Date: A copy of facility license is required for each state of practice. Accreditation Is this Facility accredited by The Joint Commission: ☐Yes ☐No Joint Commission Program ID Number: Date of most current accreditation: Expiration Date: Is this Facility accredited by the AAAHC? ☐Yes ☐No Date of most current accreditation: Expiration Date: Is this Facility accredited by CARF? ☐Yes ☐No Date of most current accreditation: Expiration Date: Insurance Information Copy of Insurance Certificate/face sheet is required. Please provide the following information about the Facility’s current general and medical liability insurance coverage. Name of Carrier: Limits of General and Medical Liability Per Occurrence: Expiration Date: Important Facility Contacts