Get Or Ohp 3165 2020-2025

The OR OHP 3165 form serves as an agreement between clients and providers regarding health services not covered by the Oregon Health Plan. This guide provides clear, step-by-step instructions on how to fill out this form online effectively.

Follow the steps to complete the OR OHP 3165 online.

1. Press the ‘Get Form’ button to access the OR OHP 3165 form and open it in the online editor.
2. Begin with the provider section. Choose the role of the provider by checking one option: rendering provider, prescribing provider, hospital, pharmacy, or ancillary provider. This identifies who is completing the form.
3. Next, specify the services requested, including treatments, equipment, supplies, and medications. Fill in the service codes relevant to the services if available.
4. Indicate the expected date(s) of service. If the services will span multiple months, clarify the frequency and provide start and end dates.
5. Describe the condition being treated briefly and input the estimated fees for the services ranging from a minimum to a maximum amount.
6. Check one of the statements regarding additional costs associated with the services. If there might be other costs, check all applicable options such as lab, X-ray, hospital, or anesthesia.
7. Confirm through the selected statements that the provider has attempted all reasonable covered treatments, has informed about non-covered services, and has discussed other choices.
8. Fill in the provider's name, national provider identifier (NPI), and provide a signature along with the date.
9. Proceed to the client section, where the client must input their name, date of birth (DOB), and client ID number.
10. The client should confirm their understanding of the terms regarding service costs and sign the agreement. If signed by a representative, include their name and ensure proof of authority is present.
11. A witness must also sign and print their name along with the date of signing provided.
12. Finally, review the complete form and save any changes. You can choose to download, print, or share the form as necessary.

Complete your OR OHP 3165 form online today to ensure timely health services.