Get Ohp 3113 2020

This guide provides a step-by-step approach to completing the Ohp 3113 enrollment form for Oregon Medicaid. Whether you are new to this process or need a refresher, this guide aims to support you in filling out the form accurately and effectively.

Follow the steps to complete the Ohp 3113 form online.

1. Click the ‘Get Form’ button to access the Ohp 3113 form and open it in your form editor.
2. Begin by filling out the individual provider information. Complete all applicable fields, including last name, first name, middle initial, date of birth, and social security number.
3. Enter the National Provider Identifier (NPI) and provide details about the provider’s specialty and taxonomy. If necessary, attach additional documentation for this section.
4. Provide the effective date and end date for the provider's license, along with the license number and licensing board details. Include the effective and expiration dates of the license.
5. If applicable, include the name of the agency or program that certified the employee, for those who are part of outpatient behavioral health or substance abuse disorder programs.
6. If the provider has a Medicare Provider Transaction Access Number (PTAN), please enter this information.
7. For out-of-state Medicaid providers, include the other state Medicaid provider ID and state of issue.
8. Fill in the service location with a valid physical address (not a PO Box), including room or suite number, county, phone number, and fax number.
9. If the mailing address differs from the service location, provide the mailing address including street or PO Box, room or suite number, city, state, and ZIP+4 code.
10. If necessary, provide a pay-to address which may differ from the mailing address, including relevant details.
11. Select the appropriate Oregon Medicaid provider type from the provided options, ensuring to check all applicable types.
12. Indicate the reason for enrollment and the effective date requested for this enrollment. Ensure the effective date is not older than one year from the receipt date.
13. Complete the group informations sections. This includes the group's legal name, group NPI, and group Oregon Medicaid ID, along with contact’s name and email.
14. Once all fields are accurately filled out, review the entire form for completeness. Ensure that you have included all necessary attachments.
15. After finalizing your entries, you can save changes, download, print, or share the completed form as needed.

Take the next step in your provider enrollment by completing the Ohp 3113 form online today.