Ohp 3113 form-2026

1. Click ‘Get Form’ to open the ohp 3113 form in the editor.
2. Begin by filling out the 'Individual provider information' section. Enter your last name, first name, middle initial, date of birth, SSN, and NPI if applicable. Ensure all fields marked with an asterisk (*) are completed to avoid processing delays.
3. Next, provide your 'Address information.' Input the service location address where services are rendered, including physical address details and contact numbers. If different addresses are required for mail or payment, fill those sections accordingly.
4. In the 'Medicaid enrollment information' section, enter your Out-of-State Medicaid Provider ID and state of issue if you are not an Oregon provider. Select your Oregon Medicaid provider type using the provided codes.
5. Complete the 'Group affiliation' section with the legal business name and contact details for follow-up inquiries regarding your enrollment request.
6. Finally, review all entered information for accuracy before signing at the bottom of the form. Certify that all details are true and complete.

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