"Not My Patient" Correction Request Form

* All areas need to be completed before the request can be acted upon.
If a date of transfer or date of release from practice is not included, the form cannot be processed.

The benefit program for OhioHealth and Aetna insureds does not require selection of a primary care physician. Therefore, claims history was used to attribute patients to individual physicians. We recognize that there are circumstances when claims do not accurately reflect a patient’s primary care selection. Please complete this form to notify OhioHealth Group (OHG) of any insured patient on your report who you are certain is no longer your patient. OHG will remove the patient from your “list” and the patient will not continue to appear on your reports.

Please print clearly. Fax the completed form and supporting information to OhioHealth Group. The fax number is 614-566-0415.


* Doctor’s name as it appears on the report:
 

* Patient’s name as it appears on the report:
 
(ex. Doe, John M)

* Please check the reason patient should be removed from your actionable report:  

Date of transfer
Date of occurrence

* Who should we contact if we need additional information?

Name:

Phone number:




Print Name


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