Prospective Provider or Group Information Form

 

Prospective Practitioner Attestations

 

All contracted OHSU Health Service Providers are required to follow federal and state laws and regulations related to providing services to OHP beneficiaries. The purpose of those laws and regulations is to ensure Member safety and provision of quality care and include requirements related to credentialing, criminal records checks, fraud, waste, and abuse, privacy, Member rights, abuse reporting, grievance and appeals, record keeping standards, and other applicable criteria. • Provider acknowledges and understands that if they have been seeing OHSU Health Services members and have not obtained a prior authorization, services may not be reimbursed and, per OAR 410-120-1280, the member may not be billed. • Provider acknowledges and understands that according to 42 CFR §447.15 and OAR 410-120-1280 members may not be charged a co-pay, nor billed for services rendered. • Provider acknowledges and understands that members cannot be billed for missed appointments, services provided which were not authorized, or any portion of charges which were not reimbursed by OHSU Health Services. • Provider acknowledges and understands that they cannot bill OHSU Health Services for a missed appointment or services which were not rendered. • Provider acknowledges that they have reviewed and understand OHP contracted rates. • Provider understands that all NPIs which appear on a claim must have a Division of Medical Assistance Programs (DMAP) number in order to be reimbursed for services rendered. • Provider understands that, should they be approved to provide services to OHSU Health Services members, that they will be held accountable to the Fraud, Waste, and Abuse regulations set forth by the Centers for Medicare and Medicaid Services. Fraud, Waste, and Abuse overview available on the Health Share website at http://www.healthshareoregon.org/for-providers/fraud-waste-and-abuse.html. • Provider understands the rules and regulations established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Provider agrees to comply with all HIPAA laws. Provider will never disclose protected health information (PHI) in a manner that is not in compliance with HIPAA laws.

 

• Provider acknowledges and understands that submitting this form to OHSU Health Services does not guarantee network participation. • If you are seeing OHSU Health Services members and have not obtained a prior authorization, services may not be reimbursed and, per OAR 410-120-1280 the member may not be billed.

 

Organizational Information:

 

Medicaid enrollment is required for application. Please answer yes and proceed if you are Medicaid enrolled. If you are not, please contact OHSUHealthPrvRelations@ohsu.edu for questions.

 
 
 

**Please note: We are closed to adding new primary care providers at this time.

 
 
 
 
 

 

Practice Information

 
 
 
 
 
 
 

Please select one

 
 
 
 
 
 
 
 

**Please be thorough in describing how the specific populations are culturally supported in your practice.

 
 
 
 
 
 
 
 
 
 

 

Provider Information

 
 

Type: Certification/Degree/Licensure

 
 

 

Contact Information