Get Or Ohp 3113 2019

The OR OHP 3113 is a crucial form for enrolling providers with Oregon Medicaid for non-reimbursement purposes. This guide will walk you through the steps needed to successfully fill out the form online, ensuring a smooth submission process.

Follow the steps to complete the OR OHP 3113 form online.

1. Select the ‘Get Form’ button to access the OR OHP 3113 form and open it in your preferred editor.
2. Complete the individual provider information section. Provide required details such as last name, first name, middle initial, date of birth, and social security number.
3. Fill in the necessary licensing details, including the license/certification number and the respective licensing board.
4. If applicable, enter the Medicare ID and corresponding effective and expiration dates for your license or certification.
5. Complete the address information section, ensuring you provide a physical location where services will be rendered.
6. Provide the Medicaid enrollment information, including the out-of-state Medicaid provider ID if you are not an Oregon provider.
7. Enter the relevant provider types and taxonomy codes based on your enrollment needs.
8. Fill out the group affiliation information if you are associated with a group, clinic, or agency.
9. Indicate the effective date for the enrollment request, ensuring it is not older than one year from the submission date.
10. Sign the form, certifying that all provided information is true and complete. Ensure to print your name and date of signing.
11. Once completed, you can save the form, download it, print it, or share it as required.

Complete your OR OHP 3113 form online today for efficient processing.