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Personal Support Worker (NSW) Provider Enrollment Application and Agreement (Revised 06/29/2016)This Provider Enrollment Application and Agreement (Agreement), sets forth the conditions and agreements
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How to fill out this provider enrollment application

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To fill out this provider enrollment application, follow the steps below:
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Open the provider enrollment application form.
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04
Fill in all the required fields accurately.
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Attach any supporting documents or certificates as specified.
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Who needs this provider enrollment application?

01
Anyone who wishes to become a provider in this particular system or network needs to fill out this provider enrollment application. This application is required by both individuals and entities who want to offer their services as providers, such as healthcare professionals, clinics, hospitals, or other types of service providers. The application helps in ensuring that the providers meet the necessary criteria and can be properly enrolled in the system.

What is This Provider Enrollment Application and Agreement (Agreement), sets forth the conditions and agreements for being enrolled as a Medicaid Personal Support Worker (Provider) with the State of Oregon Department of Human Services (DHS), Office Form?

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This Provider Enrollment Application and Agreement (Agreement), sets forth the conditions and agreements for being enrolled as a Medicaid Personal Support Worker (Provider) with the State of Oregon Department of Human Services (DHS), Office template instructions

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This provider enrollment application is a form that must be completed by healthcare providers who wish to participate in a specific health insurance plan or program.
Healthcare providers who want to join a particular health insurance plan or program are required to file this provider enrollment application.
The provider enrollment application can be filled out online or by printing out a paper form and submitting it through mail or fax. Applicants must provide accurate and detailed information about their practice and credentials.
The purpose of this provider enrollment application is to collect necessary information about healthcare providers in order to verify their eligibility to participate in a specific health insurance plan or program.
The provider enrollment application requires information such as the provider's name, contact information, professional credentials, practice location, specialty, and payment preferences.
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