use the OHA 3974 (Disclosure Statement of Ownership and Control Interest). PURPOSE The primary use of the Disclosure Statement is to comply with 42 CFR Part 455 Subpart B and OAR 410-120-1260(6)(c) and to facilitate monitoring of providers sanctioned by the U.S. Department of Health and Human Services (DHHS) Centers for Medicare and Medicaid Services (CMS), DHHS Office of Inspector General, another state, the Oregon Health Authority (OHA), or the Oregon Department of Justice Medicaid Fraud Uni.
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How to fill out the OR OHA 3973 online
The OR OHA 3973 form, known as the Provider Enrollment Disclosure Statement, is essential for individual performing providers to comply with Medicaid regulations. This guide will provide you with step-by-step instructions on how to fill out this form online effectively.
Follow the steps to successfully complete the OR OHA 3973 form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Provide your identifying information, including your provider name, location, Social Security Number (SSN), date of birth (DOB), and tax identification number (TIN). Ensure that you attach a copy of your IRS confirmation letter or Federal Tax Deposit Coupon to support your TIN.
- Complete the provider certifications section. Answer questions regarding any sanctions, disciplinary actions, or convictions related to public assistance, Medicare, or Medicaid. Attach additional pages as necessary for explanations.
- List names, SSNs, DOBs, and addresses for individuals with ownership or control interests, along with types of entities. If applicable, mark fields indicating that there are none or that they do not apply.
- Identify any criminal offenses by listing names, titles, and addresses for individuals with ownership interests who have been convicted. Again, indicate if there are none or if it does not apply.
- Sign the form in the provider signature section. Acknowledge the statements regarding the accuracy of information and commitment to informing the Provider Services Unit of any changes.
- Provide any remarks or additional information if needed.
- Once you have filled out all necessary fields, save your changes, download the completed form, and print it as required. Share the form as needed for submission.
Complete your OHA 3973 form online today for streamlined processing of your provider enrollment!
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Get answers to your most pressing questions about US Legal Forms API.
What is the limit for Medicaid in Oregon?
Who is eligible for Oregon Health Plan (Medicaid/SCHIP)? Household Size*Maximum Income Level (Per Year)4$39,9005$46,7376$53,5737$60,4094 more rows
What is the phone number for Oregon DMAP provider?
Call 800-336-6016 Note: Please do not provide personal information (e.g. address, social security numbers, etc.)
Does Oregon have expanded Medicaid?
Oregon has expanded free health insurance that mirrors Medicaid to all residents who qualify, regardless of their immigration status.
When did Oregon expand Medicaid?
Oregon was far ahead of the pack on Medicaid expansion and reform. The state expanded Medicaid (Oregon Health Plan) to cover people with incomes up to the poverty level in 1994.
Does Oregon have expanded Medicaid coverage?
Oregon has expanded free health insurance that mirrors Medicaid to all residents who qualify, regardless of their immigration status.
Who is eligible for Medicaid in Oregon 2023?
In 2023, that would be $90,000 for a family of four. Oregon also has special programs that make Medicaid available to many adults in treatment for breast cancer and for young adults who were in foster care. Currently, most adults qualify for the Oregon Health Plan if they make up to 138% of the federal poverty level.
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