Get Ohp 3113 Form

Filling out the Ohp 3113 Form online is a straightforward process that allows you to enroll providers with Oregon Medicaid. This guide provides a step-by-step overview to help you navigate each section of the form effectively.

Follow the steps to complete the Ohp 3113 Form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin with the individual provider information section. Fill in all required fields marked with an asterisk (*), including last name, first name, middle initial, date of birth, Social Security number (SSN), and National Provider Identifier (NPI) if applicable.
3. Provide the license or certification number and the licensing or certification board information. Include the Medicare ID (PTAN) if you are enrolled as a Medicare provider, along with the license's effective and expiration dates.
4. Enter the service location address where services are rendered, ensuring it includes a physical street address. Fill in required fields like county, full address, phone, and fax number.
5. If the mail-to address is different from the service location, provide that information as well. Repeat this for the pay-to address if it differs from the mail-to address.
6. Complete the Medicaid enrollment information. If you are an out-of-state provider, enter your out-of-state Medicaid Provider ID and state of issue. Select the appropriate Oregon Medicaid provider type and enter taxonomy codes as required.
7. Provide the legal business name and Oregon Medicaid ID for the group or agency requesting enrollment, along with contact details including name, email, phone, and fax number.
8. Fill in the effective date requested for this enrollment and provide the reason for enrollment by selecting the applicable options.
9. Lastly, certify the information provided by signing the form, including your printed name and date of signing.
10. Once all steps are completed, save your changes and choose your desired action: download, print, or share the form as necessary.

Complete your documentation online today with confidence!