Get Or Oha 3973 2013-2025

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.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. Provide any remarks or additional information if needed.
8. 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!