Get Ohp 3140. Provider Revalidation Form

The OHP 3140. Provider Revalidation Form is essential for each provider seeking revalidation with Oregon Medicaid. This guide provides step-by-step instructions to effectively complete the form online, ensuring all necessary information is accurately submitted.

Follow the steps to fill out the OHP 3140. Provider Revalidation Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Begin with the individual provider section. You will need to enter the individual's last name, first name, middle initial, date of birth, social security number (SSN), license/certification number (if applicable), national provider identifier (NPI), and Oregon Medicaid ID. Make sure to fill in all applicable fields.
3. Next, move to the organization information section if applicable. Here, provide the legal business name, employer identification number (EIN), NPI, Oregon Medicaid ID, and Medicare ID (PTAN). As a reminder, complete and submit a new OHA 3974 along with this revalidation form.
4. Enter the service location where the services are delivered. Include the full physical address, city, state, and ZIP+4 code. It is important to avoid using a P.O. Box.
5. Complete the provider attestation section. Review the statement carefully, and then sign and date the form. If the contact person differs from the provider or authorized representative, fill in their name, email, and phone number.
6. Once all sections are completed, ensure that all fields are filled as required. You can then save changes, download the completed form, print it out, or share it as needed.

Complete your documents online to ensure swift and accurate processing.