Get Or Ohp 3113 2024-2025

The OR OHP 3113 form is essential for enrolling or re-enrolling providers into the Oregon Medicaid system. This guide provides clear, step-by-step instructions for completing this form online, ensuring that users can easily navigate the necessary fields.

Follow the steps to fill out the OR OHP 3113 form online.

1. Click ‘Get Form’ button to access the form and open it in the online editor.
2. Fill in the date field with the current date. This is important for processing your application.
3. In the 'From' section, enter your name or the name of the organization submitting the form.
4. Indicate the number of pages you are submitting, including the coversheet.
5. Provide a contact phone number where you can be reached.
6. Select and check the appropriate document type box, choosing only one option that applies to your submission: Provider Enrollment, Claim Documentation, Prior Authorization, Hearing Documentation, Grievance Documentation, or Correspondence.
7. If selecting Prior Authorization, indicate the processing urgency by checking the appropriate box for Routine, Urgent, or Immediate processing.
8. In the 'Justification' section, summarize any additional information required for Urgent or Immediate processing.
9. Complete the 'Documentation Identification Numbers' section by entering the relevant Provider ID, Recipient ID, and any other applicable identifiers.
10. Fill in all required individual provider information, such as last name, first name, date of birth, social security number, and National Provider Identifier (NPI). Ensure that this information is accurate.
11. Provide the necessary address information, including service location and mailing address if different.
12. If applicable, enter group affiliation information.
13. Specify the requested enrollment effective date. If omitted, the process will consider the date of receipt.
14. Finish by entering the name and title of the authorized representative, signing the form, and dating it.
15. Once completed, save the changes, then download or print the form as necessary. Ensure that all information is accurate before submission.

Complete your documents online to ensure timely processing.