OHP Client Agreement
to Pay for Health Services

This is an agreement between a Client and a Provider, as defined in OAR 410-120-0000. The client agrees to pay the provider for health service(s) not covered by the Oregon Health Plan (OHP), coordinated care organizations (CCOs) or managed care plans. For the purposes of this Agreement, services include, but are not limited to, health treatment, equipment, supplies and medications.

Provider Section
Provider completing this form is (check one):
Service(s) requested:
Service codes (CDT/CPT/HCPCS/NDC):
Expected date(s) of service (if services are to occure over serveral months, please list the frequency, beginning and expected end dates):
Condition being treated:
Estimated Fees $ Check one of the follwing statements about these fees:

Provider name:
Provider Signature:
OHP client section
Client Name:
Client ID#:
I understand:
I have been fully informed by the provider of all available medically appropriate treatment, including services that may be paid for by the Oregon Health Authority (OHA) or OHA - contracted CCOs or managed care plans, and I still choose to get the specified service(s) listed above.
Client (or representative’s) signature – Representative must have proof of legal authority to sign for this client. If signed by the client’s representative, print their name here:
Witness Signature:
Witness Name:
This agreement is valid only if the estimated fees listed above do not change and the services are scheduled within 30 days of the member’s signature.
Client - Keep a copy of this form for your records.
OHP 3165 (Rev.8/1/16)
Attention OHP Client - Read this information carefully before you sign

Before you sign you should be sure each service is not covered by OHP or your Coordinated Care Organization (CCO) or managed care plan. Here are some things you can do:

Check to make sure the service is not covered
OHA, your CCO or plan will send you a Notice of Action if they do not cover a service that your provider requests. If you did not receive a Notice of Action, ask your CCO, plan or provider to send you one so you can be sure the service is not covered by OHP.

Request an Appeal and or Hearing
Once you have a Notice of Action, you can request an Appeal or Hearing. Read the Notice of Action carefully. It will explain why the service was denied. It will also give you information about your right to appeal the denial or ask for a hearing.
If you also have Medicare, you may have other Appeal rights. If you have both OHP and Medicare, call 800-Medicare (800-633-4227) or TTY 711.

Check to see if there are other ways to get the service
Ask your provider if:
  • They have tried all other covered options available for treating your condition.
  • There is a hospital, medical school, service organization, free clinic or county health department that might provide this service, or help you pay for it.

Will your OHP benefits, or any other health insurance you may have, change soon? If so, try to find out if this service will be covered when your benefits change.

Ask about reduced rates and discounts
Ask your provider if they can offer you a reduced rate for the service or if they offer discounts for people who pay for services privately. They may have nothing to offer you, but you won’t know unless you ask.

Get a second opinion
You may find another provider who will charge you less for the service.

Additional costs
There may be services from other providers – like hospital, anesthesia, therapy or laboratory services – that go with the service you want. You will have to pay for these, too. Ask your provider for the names and phone numbers of the other providers. Contact those providers to find out what their charges will be.


Attention Provider - Relevant Oregon Administrative Rules (OARs)

Requirements of this Agreement are outlined in OAR 410-120-1280, Billing, and 410-141-3395, Member Protection Provisions. These rules can be found online at http://arcweb.sos.state.or.us/pages/rules/oars_400/oar_410/410_tofc.html.

OHP 3165 (Rev.8/1/16)
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