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HEALTH SYSTEMS DIVISION Provider Enrollment UnitNonPayable Provider Enrollment Form Uses this form to enroll providers with Oregon Medicaid for reasons other than direct reimbursement. Fax the completed
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How to fill out ohp 3113 form
How to fill out ohp 3113 form
01
Obtain a copy of the OHP 3113 form.
02
Begin by entering the date at the top of the form in the designated field.
03
Provide your personal information, including your name, address, phone number, and email address, in the appropriate sections.
04
Indicate whether you are the patient or the patient's representative.
05
Fill out the patient's information, including their name, date of birth, gender, and contact information.
06
Complete the section regarding the patient's medical history, including any relevant diagnoses or conditions.
07
Provide information about the patient's healthcare provider, including their name, address, and contact information.
08
Indicate the type of service or treatment being requested and provide any supporting documentation if required.
09
Sign and date the form in the designated sections.
10
Review the completed form for accuracy and make any necessary corrections before submitting it.
Who needs ohp 3113 form?
01
The OHP 3113 form may be needed by individuals who are seeking certain healthcare services or treatments. This can include patients who are applying for or renewing their coverage under the Oregon Health Plan (OHP), as well as their representatives who are assisting them in the process.
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What is ohp 3113 form?
The OHP 3113 form is a reporting form used to provide information about certain healthcare services.
Who is required to file ohp 3113 form?
Healthcare providers and facilities that have provided specific services are required to file the OHP 3113 form.
How to fill out ohp 3113 form?
The OHP 3113 form can be filled out electronically or manually by providing the required information in each section as indicated.
What is the purpose of ohp 3113 form?
The purpose of the OHP 3113 form is to report detailed information about healthcare services provided for billing and tracking purposes.
What information must be reported on ohp 3113 form?
The OHP 3113 form requires information such as patient demographics, services provided, diagnoses, and billing codes.
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