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Dmap 3113 Form 2014

Use a Dmap 3113 Form 2014 template to make your document workflow more streamlined.

(NPI): Provider specialty and taxonomy (attach copy if more space is needed) : Specialty: 6. 8. 10. First name Middle initial 3. DOB: Taxonomy: Effective date: End date: License number: 7. Licensing Board: License effective date: 9. License expiration date: For employees of outpatient behavioral health and substance abuse disorder programs only: Name of agency or program that certified this employee : 11. Medicare PTAN: 12. For out-of-state Medicaid providers only: Other State...

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What is the OHA 3113 Form

The OHA 3113 form is a crucial document used for the Oregon Medicaid provider enrollment process. This form is specifically designed for healthcare providers seeking to participate in the Oregon Health Authority (OHA) Medicaid program. By completing the OHA 3113, providers can ensure they meet the necessary requirements to deliver services and receive reimbursement for care provided to Medicaid recipients in Oregon.

How to Use the OHA 3113 Form

Using the OHA 3113 form involves several steps to ensure accurate completion. First, gather all required information, including personal identification details, business information, and any necessary supporting documents. Next, fill out the form carefully, ensuring that all sections are completed accurately. Once the form is filled out, it should be submitted according to the instructions provided, either online or via mail, to the appropriate OHA office.

Steps to Complete the OHA 3113 Form

Completing the OHA 3113 form requires attention to detail. Follow these steps:

  • Begin by downloading the form from the official OHA website.
  • Fill in your personal and business information, ensuring accuracy.
  • Provide any required documentation, such as proof of credentials or licenses.
  • Review the completed form for any errors or omissions.
  • Submit the form as directed, either electronically or by mail.

Legal Use of the OHA 3113 Form

The OHA 3113 form must be completed in compliance with state and federal regulations governing Medicaid services. This includes adhering to the requirements outlined by the Oregon Health Authority and ensuring that all information provided is truthful and accurate. The legal validity of the form is supported by adherence to these regulations, making it essential for providers to understand their obligations when submitting the form.

Key Elements of the OHA 3113 Form

Several key elements must be included in the OHA 3113 form for it to be valid:

  • Provider's name and contact information.
  • Type of services offered.
  • Tax identification number.
  • Proof of professional credentials.
  • Signature of the provider or authorized representative.

Form Submission Methods

The OHA 3113 form can be submitted through various methods to accommodate different preferences:

  • Online Submission: Providers can fill out and submit the form electronically through the OHA portal.
  • Mail Submission: The completed form can be printed and mailed to the designated OHA office.
  • In-Person Submission: Some providers may choose to deliver the form directly to an OHA office.

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