OHP 3165 OHP Client Agreement to Pay for Health Services-2026

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47 votes

The document is an OHP Client Agreement to Pay for Health Services, outlining the terms under which a client agrees to pay for health services not covered by the Oregon Health Plan. It includes sections for both the provider and client, detailing the services requested, estimated fees, and the client's acknowledgment of their financial responsibility. The document emphasizes the importance of understanding coverage options and encourages clients to explore alternative treatment avenues before signing.

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Click ‘Get Form’ to open it in the editor.
Begin with the Provider section. Select the type of provider completing the form by checking the appropriate box: Rendering provider, Prescribing provider, Hospital, Pharmacy, or Ancillary provider.
In the Services requested field, list all services including treatment, equipment, supplies, and medications. Be sure to include service codes where applicable.
Indicate the expected date(s) of service and specify how often these services will occur. Include start and end dates if necessary.
Fill in the condition being treated and provide estimated fees for the services listed. Check one statement regarding additional costs that may apply.
Complete the Client section by entering your name, date of birth, and client ID number. Review all statements carefully before signing.
Ensure that any representative signing on behalf of the client has proof of legal authority. Don’t forget to add witness signatures as required.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Do I have to pay for an Oregon Health Plan?

The cost of the Oregon Health Plan is based on your income and household size. Most people who enroll in the program will not have to pay any monthly premiums, but there may be co-payments for some services.

Does Oregon Health Plan pay for therapy?

OHP covers behavioral health services. These are services to treat substance use, problem gambling and mental health disorders. You do not need a referral from your primary care provider to get treatment. If you need help accessing behavioral health services, contact your CCO.

Who pays for the Oregon Health Plan?

The Oregon Health Plan (OHP) is a program that pays for low-income Oregonians healthcare. The State of Oregon and the US Governments Medicaid program pay for it.

How much does the Oregon Health Plan cost?

The Oregon Health Plan (OHP) is a state-funded program that provides free or low-cost health coverage to eligible Oregon residents. It is designed to assist individuals and families who meet specific income and other criteria.

Is the Oregon Health Plan free?

The Oregon Health Plan (OHP) is free health coverage from the State of Oregon. People who meet income and other requirements can get the Oregon Health Plan. OHP covers medical, dental, and mental health care.

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Is OHP completely free?

OHP provides free health coverage. OHP may cover medical, dental, mental health care, and help with substance use disorders or addiction. The Oregon Department of Human Services (ODHS) makes sure people qualify for OHP. Once you are approved, you will work with the Oregon Health Authority (OHA) to manage your care.