Get the free OHA 3972. Provider Enrollment Information

HEALTH SYSTEMS DIVISION Provider Enrollment Unit PrintProvider Enrollment Information Clear FormComplete all applicable information. Individual provider information Last name:First name:Middle initial:Date

How to fill out oha 3972 provider enrollment

How to fill out oha 3972 provider enrollment

1. To fill out OHA 3972 provider enrollment form, follow these steps:
2. Download the OHA 3972 provider enrollment form from the official website of the Oregon Health Authority (OHA).
3. Carefully read the instructions provided with the form to understand the requirements and gather all the necessary information.
4. Fill in your personal information, such as your name, contact details, and Social Security Number (SSN).
5. Provide details about your professional background, including your education, qualifications, and any licenses or certifications you hold.
6. If applicable, indicate the type of medical services or care you offer, along with any specialty areas or expertise.
7. Complete the sections related to your billing practices, including your Tax Identification Number (TIN) and payment preferences.
8. Attach any supporting documents required, such as copies of your professional licenses or certifications.
9. Review the completed form to ensure all the information is accurate and legible.
10. Sign and date the form.
11. Submit the filled-out OHA 3972 provider enrollment form by mail or electronically, as specified in the instructions.
12. If submitting by mail, make sure to keep a copy for your records.
13. Await confirmation from OHA regarding the status of your provider enrollment application.

Who needs oha 3972 provider enrollment?

1. OHA 3972 provider enrollment is needed by healthcare professionals who wish to enroll as providers with the Oregon Health Authority (OHA).
2. This form is specifically required for individuals or organizations seeking to offer medical services or care within the OHA's programs or networks.
3. This includes healthcare practitioners, clinics, hospitals, laboratories, and other health service providers.
4. Regardless of whether you are an individual practitioner or an organization, if you intend to participate in the OHA's healthcare programs, you will need to complete the OHA 3972 provider enrollment process.

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What is oha 3972 provider enrollment?

OHA 3972 provider enrollment is the process by which healthcare providers enroll with the Oregon Health Authority (OHA) to participate in the state's healthcare programs.

Who is required to file oha 3972 provider enrollment?

Healthcare providers who wish to participate in Oregon's healthcare programs are required to file OHA 3972 provider enrollment.

How to fill out oha 3972 provider enrollment?

To fill out OHA 3972 provider enrollment, healthcare providers need to complete the application form provided by the Oregon Health Authority and submit all required documentation.

What is the purpose of oha 3972 provider enrollment?

The purpose of OHA 3972 provider enrollment is to ensure that healthcare providers meet certain standards and qualifications to participate in Oregon's healthcare programs.

What information must be reported on oha 3972 provider enrollment?

Healthcare providers must report information such as their contact details, licensure information, accreditation, and any relevant certifications on the OHA 3972 provider enrollment form.