Ohp 3113-2026

1. Click ‘Get Form’ to open the ohp 3113 in the editor.
2. Begin by filling out the individual provider information. Enter the last name, first name, middle initial, and date of birth in the designated fields.
3. Provide the Social Security Number (SSN), National Provider Identifier (NPI), and license details including license number, effective date, and expiration date.
4. For outpatient behavioral health employees, include the agency or program name that certified them. If applicable, enter Medicare PTAN and any out-of-state Medicaid Provider ID.
5. Complete the service location section with a physical address (not a PO Box), including county and contact numbers.
6. Select the Oregon Medicaid provider type from the list provided and indicate reasons for enrollment by checking all that apply.
7. Finally, provide group information if enrolling under a group or clinic, including legal name, NPI, Oregon Medicaid ID, contact name, and email.

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