Get Or 440-2278 2013-2025

Filling out the OR 440-2278 form online can streamline the application process for retainer medical practices. This guide presents a step-by-step approach to ensure users complete each section accurately and efficiently.

Follow the steps to successfully complete the OR 440-2278 form.

1. Click the ‘Get Form’ button to obtain the OR 440-2278 form and open it in your online editor.
2. In the 'Applicant information' section, provide the required details. This includes the name of the applicant, domicile, date established, and federal employer identification number (FEIN). Make sure to fill in the assumed business name and any other identities if applicable.
3. Continue by entering the mailing address, including line 1, line 2, city, state, phone, fax, zip, and email. Repeat the same for the physical address.
4. Identify the administrative contact person by providing their name, mailing address details, and contact information.
5. Input details regarding the registered office and agent for legal services in Oregon, including the name and full address.
6. List the names and Oregon license numbers of all providers who will deliver services through the retainer medical practice.
7. Document the physical and mailing addresses, along with contact details for each location providing retainer medical services.
8. In the 'Experience and expertise' section, describe your background or training related to retainer medical practices, including years of practice in this area.
9. List any other jurisdictions where the applicant holds or has held relevant licenses, registrations, or certifications over the past 10 years.
10. Answer the questions regarding any past license issues or enforcement actions. If applicable, provide information about the agency and the nature of the actions.
11. Attach a biographical affidavit if required for the board of directors or any governing body associated with the applicant.
12. In the 'Financial responsibility' section, indicate whether the applicant has filed for bankruptcy within the last 25 years and provide reasoning if applicable.
13. Provide a detailed business plan outlining how services will be monitored and how fees will be repaid if services promised are not fulfilled.
14. Attach relevant marketing materials and agreements intended for the certification period.
15. In the 'Applicant attestations' section, review and affirm the statements, ensuring accuracy and completeness before signing.
16. Once all fields are completed, review the form for accuracy, then save changes, and choose to download, print, or share the completed OR 440-2278 form as needed.

Complete your OR 440-2278 form online to ensure your retainer medical practice complies with the necessary requirements.