Ohio Independent Provider Network Listing Form

Ohio Independent Provider Network

Nurses Providing Exceptional Care

Independent Provider Nurse Listing Form

There is a $10.00 Availability Listing Fee (Per Region) for 1 year.
To assist with the needs of Ohio Medicaid (Waiver/ Private Duty)
consumers, we ask that only Active Waiver/ PDN Providers serving these
clients list their availability on this website. After completion of this form,
you will be redirected to a page with the "Buy Now" button -or- you may
send a check to: Shasme Jones, 7235 Scottwood Avenue, Cincinnati, OH
45237

Shasme Jones

Create Your Badge

*Click here to view R egions & let us know wh ere to list your availability.

Your Name & Title:

Email Address:

Phone Number:

Your Provider Number
(Will not be listed):

In what Region
should we list you?

Client Preference

Provide in the space below: A brief summary of
the days, shifts, or hours you are available. Your
contact preference for consumers to contact you.
List pertinent nursing experience. 25 word Max

You will be listed ASAP. Please allow at least 24 hours.
* Please remember to update any of your information should it
   change.
                            Thanks for your cooperation!