Complete form to allow the financial advisor on file to place trades via a automated telephone system, ohionational. - Enter the seven-digit Medicaid provider number or your ten-digit National Provider Identifier.Be sure to include your Insurance Information Exchange Account Number. • Fill in the following blocks in Part A: Name, address, city, state, zip code, company,. Complete Ohio specific bond form (INS3222). Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. The Supplemental Instructions (PDF) provide guidance for completing the OMBapproved Part A NMSN form. You must include copies of the following documents, as applicable, with this completed application. Use this checklist as a guide: State License. Must have active public insurance adjuster license in resident state.