Submit a request

Do not include protected health information in the subject field.

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.

OHA 3974 Disclosure Statement form: https://www.oregon.gov/oha/HSD/OHP/Tools/Provider%20Disclosure%20Statement%20of%20Ownership%20OHA%203974.pdf

OHA 3975 Provider Enrollment Agreement form: https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le3975.pdf

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

Only individual accounts can register. Group or shared accounts are not allowed to register.

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 Tax ID must be 9 digits 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.

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.

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

Please attach the spreadsheet of claims and include the claim #, member id#, date of service and reason for reprocess in the excel document.

Please provide an explanation for "other" biller.

This is the person Ayin will work with during the testing process and will submit the actual claim files.

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.

Add file or drop files here