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Get OR OHP 3165 2020-2024

Gon Health Plan (OHP), the Oregon Health Authority (OHA) or OHA-contracted managed care entities (MCEs). Provider section Provider completing this form is (check one): Rendering provider (the person providing the service) Prescribing provider Hospital Pharmacy Ancillary (other) provider: Services requested. These include, but are not limited to, treatment, equipment, supplies and medications. Service codes (CDT/CPT/HCPCS/NDC): Expected date(s) of service (if services wi.

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