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Do not include protected health information in the subject field.

OHA 3974 Disclosure Statement form:

OHA 3975 Provider Enrollment Agreement form:

(Urgent - work stoppage issue) (High - significantly impacting work) (Normal - can temporarily work around the issue) (Low - minimal business impact or inquiry)

If this is needed urgently, please contact CIM Support directly at 503-584-2169 option 2 Monday-Friday 8AM-5PM.

*NOTE: Required by CMS Rule CMS-6028-FC*

*NOTE: Required by CMS Rule CMS-6028-FC*

The NPI must be 10 digits in length.

The taxonomy must be 10 characters in length.

The NPI must be 10 digits in length.

The Name, Title, SSN, and Date of Birth must be supplied for all owners and officers with a controlling interest of 5% or more in the organization. If no one person is an owner or has a controlling interest of 5% or more, this information will need to be supplied for the CEO, CCO, or controlling officer in the organization. This is required by CMS Rule CMS-6028-FC.

Access to a New Tax ID, Office, or CIM Application does not constitute a modification/update, and the New CIM Account form needs to be completed and submitted.

The NPI must be 10 digits in length.

The Tax ID must be 9 digits in length.

The Payer ID must be 5 characters in length.

A W9 form MUST be attached below or PH TECH will not be able to process this request.

For example, Member Name, Address, Language, etc.

If you are providing print ready templates, please be sure to attach them to this request. For example: merge template, handbook, postcard, envelopes, or other items.

Please provide as much detail as possible. Example: All members on Plan ABC, all children up to age 18 on plan XYZ, etc.

Sending one per household will eliminate one household receiving duplicates for each family member.

We require that you attach a copy of your Business Associates Agreement (BAA).

Please enter a brief summary above. You can include PHI in this description field. Requests submitted in this portal adhere to HIPAA compliance standards. Please remember to observe minimum necessary guidelines when transmitting PHI.

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