Get Oha 3974

The Oha 3974 form is essential for disclosing ownership and control information required by the Oregon Health Authority. This guide provides a clear, step-by-step process for users to complete the form online with ease and accuracy.

Follow the steps to successfully complete the Oha 3974 online.

1. Click the ‘Get Form’ button to access the Oha 3974 form and open it in your online editor.
2. Begin with Section I. Disclosing entity information. Fill in the legal name of the provider (individual, agency, facility, or group), the 'Doing Business As (DBA)' name, the tax identification number (TIN), whether it's a Social Security Number (SSN) for an individual or an Employer Identification Number (EIN) for an entity, the service address, and the National Provider Identifier (NPI).
3. Move to Section II. Disclosure Information. Here, list the names and addresses of individuals or corporations with an ownership or control interest. For individuals, include their date of birth (DOB) and SSN; for corporations, include the TIN. Additionally, list all subcontractors related to disclosing entity owners as spouse, parent, child, or sibling.
4. For each individual or corporation reported, answer whether they have ever been sanctioned, excluded, or convicted of a criminal offense related to Medicare, Medicaid, or any federal program. Provide conviction details where applicable.
5. Section III is only for business transactions, complete this section only if requested by CMS or OHA. Document any significant business transactions with subcontractors exceeding $25,000.
6. In Section IV, disclosing entity’s attestation, review the information provided. Certify its accuracy by filling in your name, title, and signing the form. Don't forget to add the date.
7. Once complete, save your changes. You can download, print, or share the form as needed.

Start completing your Oha 3974 form online today!