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PAYER ID: SX136 SUBMITTER ID: Eden Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account 1 Provider Organization Practice/ Facility Name Provider Name

How to fill out sx136 providence of oregon

How to fill out sx136 providence of oregon:

1. First, gather all the necessary information. Make sure you have all the required documents and details before starting to fill out the sx136 providence of Oregon form.
2. Start by entering your personal information. This may include your name, address, contact information, date of birth, and social security number. Double-check the accuracy of the information you provide.
3. Proceed to the next section, which typically involves providing details about your income and employment. This may include your employer's name, address, and contact information, as well as your salary, wages, or any other sources of income you may have.
4. On the form, there will likely be a section where you need to describe your medical history. This may include information about any pre-existing conditions, previous surgeries, or ongoing treatments. Be sure to provide accurate and detailed information to the best of your knowledge.
5. If applicable, provide information about your current health insurance coverage. This may include details about your insurance provider, policy number, and the extent of coverage.
6. Review the completed form thoroughly. Check for any errors or missing information. It's always a good idea to have someone else look over the form as well to ensure its accuracy.
7. Finally, sign and date the form where required. Be sure to follow any additional instructions provided on the form or in the accompanying documentation.

Who needs sx136 providence of Oregon:

The sx136 providence of Oregon form is typically required by individuals who are seeking medical assistance, benefits, or coverage from Providence Health Plan in the state of Oregon. This form is specifically designed to collect relevant information about an individual's medical history, income, and insurance coverage in order to assess eligibility for various healthcare programs and services provided by Providence Health Plan. Therefore, anyone who is applying for or seeking benefits from Providence Health Plan in Oregon may need to fill out the sx136 providence of Oregon form.

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