Get Or Oha 3972 2024-2026

The OR OHA 3972 form is essential for providers enrolling in or updating their status with Oregon Medicaid. This guide will provide you with clear, step-by-step instructions for completing this form online to ensure a smooth and efficient process.

Follow the steps to fill out the OR OHA 3972 online successfully.

1. Click ‘Get Form’ button to obtain the OR OHA 3972 form and open it in your preferred editor.
2. Select the appropriate request type by choosing one of the options: 'New or re-enrollment', 'Provider update', or 'Revalidation'. Make sure to check the box if applicable.
3. Define whether the enrollment is for a 'Payable Individual' or an 'Organization' by selecting the correct option.
4. If you are filling out the form for an organization, indicate the business types that apply by checking the relevant boxes, such as 'Public provider', 'Corporation', or 'Limited Liability Corporation (LLC)'.
5. Fill in the required 'Provider Enrollment Information' section, including the individual's or organization’s legal name, National Provider Identifier (NPI), and other identifying information.
6. Provide the necessary address information, ensuring that the service location is a physical street address, not a PO Box.
7. Complete the licensing and certification information if applicable, including the number, issue date, and expiration date.
8. Make sure to include the enrollment contact details, along with appropriate contacts for financial, medical records, and billing inquiries.
9. If applicable, enter the required details for any laboratory services used and ensure to attach necessary certifications.
10. Sign the form, providing the printed name, title, and date. This confirms that all information provided is accurate.
11. Upon completing the form, review it for accuracy, then save your changes. You can choose to download, print, or share the form as needed.

Begin filling out the OR OHA 3972 online today to ensure your enrollment or update is processed promptly.