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ODH Banner State of Ohio Home Ohio Department of Heath Home
Office of Health Assurance and Licensing - EIDC User Account Request
The following information is required to obtain secure access to Health Care Provider Online Business Processing - Enhanced Information Dissemination & Collection (EIDC). By submitting this request, you swear or affirm that you are authorized to perform business processes for the facilities listed below.
First Name:*
Last Name:*
Title:*
e-mail Address:*
Secondary Contact Name:

Reason for request (at least one reason is required):*





Technical Issue Description:*

Please identify the type of facility with which you are affiliated (at least one type is required):*
(To enter multiple entities separate them by comma ",". e.g. 1234N,5678N,0123N)
Enter State ID or Medicare ID: (e.g. 1234N or 36XXXX))
Enter State ID or Medicare ID: (e.g. 1234R or 36XXXX)
Enter State ID or Medicare ID: (e.g. 0123AS or 01234DC or 36XXXX)
Enter State ID or Medicare ID: (e.g. 0123HSP or 36XXXX)
Enter FAC ID or Medicare ID: (e.g. OHXXXX OR 36XXXX)
Enter Hospital Number: (e.g. 1111,1112,1113)
Enter Program Number: (e.g. 365XXXX)

I swear or affirm that the information provided herein, and any attachments hereto, have been prepared or carefully reviewed by me and constitute a truthful and correct disclosure of all information herein. I certify that the undersigned is the operator (if the operator is an individual), the president or other officer (if the operator is a corporation), a partner (if the operator is a partner), or an authorized agent of the operator.

ODH CONTACT INFORMATION
If you have a question regarding use of this form e-mail us at liccert@odh.ohio.gov.

    
* = Required field
Enhanced Information Dissemination Version 3.0
Software release on: 07/28/2016