New form OHP Client Agreement to Pay for Health Services, DMAP 3165

The Division of Medical Assistance Programs (DMAP) has created a new form to use when billing OHP clients for non-covered services that they agree to pay for. The form, or a facsimile containing the elements in it, must be completed and signed by the provider, and signed by the client, before the non-covered service is provided. The DMAP 3165 form was created in response to an increasing number of calls from clients with billing issues and providers who have asked for a standard form they can use when a client requests a non-covered service.

Source: https://www.oregon.gov/oha/healthplan/Pages/Announcements.aspx