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Form OHP3104 Provider Enrollment Attachment - Health Centers - Oregon
What Is Form OHP3104?
This is a legal form that was released by the Oregon Health Authority - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form OHP3104?
A: Form OHP3104 is a Provider Enrollment Attachment specifically designed for Health Centers in Oregon.
Q: Who needs to fill out Form OHP3104?
A: Health Centers in Oregon who wish to enroll as a provider in the Oregon Health Plan (OHP) need to fill out Form OHP3104.
Q: What information is required on Form OHP3104?
A: Form OHP3104 requires information about the Health Center, such as its legal name, address, contact information, and NPI number. It also requires information about the designated official and health center managers.
Q: How do I submit Form OHP3104?
A: Form OHP3104 can be submitted electronically through the Oregon Health Plan Provider Portal or by mail to the address provided on the form.
Form Details:
- Released on May 1, 2016;
- The latest edition provided by the Oregon Health Authority;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form OHP3104 by clicking the link below or browse more documents and templates provided by the Oregon Health Authority.
Download Form OHP3104 Provider Enrollment Attachment - Health Centers - Oregon
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