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Blank Oregon Practitioner Application Form

The Oregon Practitioner Application is a vital document used for the credentialing and recredentialing of healthcare practitioners in Oregon. Established by House Bill 2144 in 1999, this application is designed to standardize the process for hospitals and health plans. Completing this form accurately is essential for practitioners seeking to maintain their professional status within the state's healthcare system.

Outline

The Oregon Practitioner Application form is a crucial document for healthcare professionals seeking to maintain their credentials within the state. This form is designed to facilitate the recredentialing process for practitioners, ensuring that they meet the necessary standards set forth by the Advisory Committee on Physician Credentialing Information (ACPCI). Key components of the application include detailed sections for personal information, professional liability action details, and a glossary of terms and acronyms to clarify any terminology used throughout the form. Practitioners must provide comprehensive information about their education, board certifications, and practice affiliations. Additionally, the form requires the submission of supporting documents such as state professional licenses and DEA certificates. Proper completion is essential; any modifications to the form's wording or format can lead to invalidation. Therefore, practitioners are advised to follow the outlined instructions meticulously, ensuring that all information is accurate and up-to-date before submission to the relevant healthcare organization.

Sample - Oregon Practitioner Application Form

OREGON PRACTITIONER RECREDENTIALING

APPLICATION

APPLICATION

PROFESSIONAL LIABILITY ACTION DETAIL (ATTACHMENT A)

GLOSSARY OF TERMS AND ACRONYMS

Purpose: Established by 2UHJRQhouse bill 2144 (1999), the $ dvisory &ommittee on 3hysician &redentialing,nformation (ACPCI) develops the uniform applications used by hospitals and

health plans to credential and recredential PRACTITIONERS within the State of 2regon.

REVIEWED, AMENDED AND APPROVED

BY THE ADVISORY COMMITTEE ON PHYSICIAN CREDENTIALING INFORMATION (ACPCI)

5/1/12

Oregon Practitioner Recredentialing Application

Prior to completing this recredentialing application, please read and observe the following:

INSTRUCTIONS

This form should be typed (using a different font than the form) or legibly printed in black or blue ink. If more space is needed than provided on original, attach additional sheets and reference the question being answered.

Modification to the wording or format of the Oregon Practitioner Recredentialing Application will invalidate the application.

Complete the application in its entirety. Keep an unsigned and undated copy of the application on file for future requests. When a request is placed, send a copy of the completed application to the health care related organization to which you are applying, making sure that all information is complete, current and accurate.

Please sign and date page 8, Attestation Questions and page 9, Authorization and Release of Information Form (and Attachment A, Professional Liability Action Detail, if applicable).

Each page of the application requires the applicant’s initials and the date on which the application was last reviewed.

Identify the health care related organization(s) to which this application is being submitted in the space provided below.

Attach copies of the documents requested each time the application is submitted.

If a section does not apply to you, please check the provided box at the top of the section.

Mail application to the requesting organization(s).

Current copies of the following documents must be submitted with this application:

State Professional License(s)

DEA Certificate or CSR Certificate

ECFMG (if applicable)

Face Sheet of Professional Liability Policy or Certificate

A curriculum vitae is optional and not an acceptable substitute.

I am applying to (please list: Hospital Staff, HMO, IPA):
for			(i.e., staff membership, network participation,
if applicable).

*Note: Please return completed application to the health care related organization to which you are applying, not to the State of Oregon.

Oregon Practitioner Recredentialing Application 5/1/12

Page 1 of 10

INITIALS:

DATE:

OREGON PRACTITIONER RECREDENTIALING APPLICATION

II.	PRACTITIONER INFORMATION				Please provide the practitioner’s full legal name.
Last name (include suffix; Jr., Sr., III):			First:			Middle:				Degree(s):

Is there any other name under which you have been known or have used since starting professional training?									Yes		No
Name(s) and year(s) used:
Home street address:						Home telephone number:				Mobile/alternate number:
						(	)			(	)
						Email address:

City:		State:						ZIP:

Country:		Birth date (month/day/year):						Birth place:
		/		/
Citizenship:		Social Security number:						Gender:
								Male		Female
Immigrant visa number (if applicable):		Visa expiration date:						Type:

III.SPECIALTY INFORMATION

This information may be included in directory listings.

Principal clinical specialty (For most current specialties list, see:		Do you want to be designated as a primary care practitioner (PCP)?
http://www.wpc-edi.com/codes):		Yes	No
Additional clinical practice specialties:

Category of professional activity, check all boxes that apply:

Clinical practice:		Other professional activities:
Full time	Part time		Administration	Teaching
Locum/temporary	Telemedicine		Research	Retired
Other (explain):			Other (explain):

	IV. BOARD CERTIFICATION/RECERTIFICATION	Does not apply
	This section does not apply to licensure.	Does not apply
	This section does not apply to licensure.
	List all current and past certifications. Please attach additional sheets, if necessary.

		Date	Expiration date
Name and address of issuing board:	Specialty:	certified/recertified	(if any)
		month/year:	month/year:

If not currently board certified, describe your intent for certification, if any, and dates of previous testing and/or intended future testing for certification below. Please attach additional sheets, if necessary.

Oregon Practitioner Recredentialing Application 5/1/12

Page 2 of 10

INITIALS: ____________DATE: _____________________________

V.	OTHER CERTIFICATIONS	Please attach copy of certificate(s), if applicable.	Does not apply
Examples include: ACLS, BLS, ATLS, PALS, NRP, AANA, Fluoroscopy, Radiography, etc.

Type:	Number:	Month/year of certification:	Month/year of expiration:

Type:	Number:	Month/year of certification:	Month/year of expiration:

Type:	Number:	Month/year of certification:	Month/year of expiration:

Type:	Number:	Month/year of certification:	Month/year of expiration:

For additional certifications, please attach a separate sheet.

VI.

PRACTICE INFORMATION

Name of primary practice/affiliation or clinic:

Department name (if hospital based):

Primary clinical practice street address:

Effective date at location, month/year:

City:

County:

State:

ZIP:

Primary office telephone number:

Primary office fax number:

Patient appointment telephone number:

(

)

Ext.:

(

)

(

)

Ext.:

Mailing/billing address (if different from above):

Attn:

Office manager:

Office manager’s telephone number:

Office manager’s fax number:

(

)

Ext.:

(

)

Exchange/answering service number:

Pager number:

Office email address:

(

)

Ext.:

(

)

Recredentialing contact and address (if different

from above):

Recredentialing contact’s telephone number:

Recredentialing contact’s fax number:

Recredentialing contact’s email address:

(

)

Ext.:

(

)

Federal tax ID number or Social Security number, if

used for

Name affiliated with tax

ID number:

business purposes:

Name of primary practice/affiliation or clinic:

Department name (if hospital based):

Secondary clinical practice street address:

Effective date at location, month/year:

City:

County:

State:

ZIP:

Secondary office telephone number:

Secondary office fax number:

Patient appointment telephone number:

(

)

Ext.:

(

)

(

)

Ext.:

Mailing/billing address (if different from above):

Attn:

Office manager:

Office manager’s telephone number:

Office manager’s fax number:

(

)

Ext.:

(

)

Exchange/answering service number:

Pager number:

Office email address:

(

)

Ext.:

(

)

Recredentialing contact and address (if different

from above):

Recredentialing contact’s telephone number:

Recredentialing contact’s fax number:

Recredentialing contact’s email address:

(

)

Ext.:

(

)

Federal tax ID number or Social Security number,

if used for

Name affiliated with tax

ID number:

business purposes:

Please list other office locations with above information on a separate sheet.

Oregon Practitioner Recredentialing Application 5/1/12

Page 3 of 10

INITIALS:

DATE:

VII.

PRACTICE CALL COVERAGE

Please provide the name and specialty of those practitioners who

provide care for your patients when you are unavailable.

NAME:

SPECIALTY:

VIII.

ADDITIONAL EDUCATION

If you have completed additional residencies,

Does not apply

internships or advanced specialized education within the past three (3) years, please provide the

following information. Please attach additional sheets, if necessary.

Complete name and street address of program:

City:

State:

ZIP:

Specialty:

Phone number:

Fax

number, if available:

(

)

(

)

From month/year:

To month/year:

Month/year of completion:

Did you complete the program?

Yes

(If you did not complete the program, please explain on a separate sheet.)

Complete name and street address of program:

City:

State:

ZIP:

Specialty:

Phone number:

Fax

number, if available:

(

)

(

)

From month/year:

To month/year:

Month/year of completion:

Did you complete the program?

Yes

(If you did not complete the program, please explain on a separate sheet.)

IX. CONTINUING MEDICAL EDUCATION Please list activities for which

you have received CME credit(s) during the past two (2) years. Please attach a separate sheet, if needed.

Does not apply

Name:	Month/year attended:	Hours:
Name:	Month/year attended:	Hours:
Name:	Month/year attended:	Hours:
Name:	Month/year attended:	Hours:
Name:	Month/year attended:	Hours:
Name:	Month/year attended:	Hours:

X.HEALTH CARE LICENSURE, REGISTRATIONS, CERTIFICATES AND

ID NUMBERS Please attach additional sheets, if necessary.

Oregon license or registration number:	Type:		Month/day/year of expiration date:

Drug Enforcement Administration (DEA) registration	number (if applicable):		Month/day/year of expiration date:

Controlled substance registration (CSR) number (if applicable):			Month/day/year issued:

Individual NPI number:	Medicare number:		DMAP number:

Oregon Practitioner Recredentialing Application 5/1/12	Page 4 of 10	INITIALS:		DATE:

XI. OTHER STATE HEALTH CARE LICENSES, REGISTRATIONS

AND CERTIFICATES Please attach additional sheets, if necessary

Does not apply

State/country:

Number:

Type:

Year obtained:

Month/day/year of expiration:

Year relinquished:

Reason:

State/country:

Number:

Type:

Year obtained:

Month/day/year of expiration:

Year relinquished:

Reason:

State/country:

Number:

Type:

Year obtained:

Month/day/year of expiration:

Year relinquished:

Reason:

XII. HOSPITAL AND OTHER HEALTH CARE FACILITY AFFILIATIONS

Please list for the past three (3) years all health care institutions where you have and/or have had clinical privileges and/or staff membership. Include all (A) affiliations in the past three (3) years, and/or (B) applications in process (i.e., hospitals, surgery centers or any other health care related facility). If more space is needed, please attach additional sheets. Do not list residencies, internships or fellowships. Please list employment in Section XIII, Professional Practice/Work History.

A. AFFILIATIONS IN THE PAST THREE (3) YEARS

Facility name:	Phone number:			Fax number, if available:		Complete address:
	(	)		(	)

Status (e.g. active, courtesy, provisional, allied			Month/day/year of appointment:
health, etc.):

Facility name:	Phone number:			Fax number, if available:		Complete address:
	(	)		(	)

Status:			Month/day/year of appointment:

Facility name:	Phone number:			Fax number, if available:		Complete address:
	(	)		(	)
Status:			Month/day/year of appointment:

If you do not have hospital admitting privileges, check here:

Please explain on a separate sheet your plan for continuity of care for your patients who require admitting.

B. APPLICATIONS IN PROCESS

Does not apply

Facility name:	Phone number:			Fax number, if available:		Complete address:
	(	)		(	)

Status (e.g. active, courtesy, provisional, allied			Month/year of submission:
health, etc.):

Facility name:	Phone number:			Fax number, if available:		Complete address:
	(	)		(	)

Status:			Month /year of submission:

Facility Name:	Phone number:			Fax number, if available:		Complete address:
	(	)		(	)

Status:			Month/year of submission:

Oregon Practitioner Recredentialing Application 5/1/12

Page 5 of 10

INITIALS:

DATE:

XIII.		PROFESSIONAL PRACTICE/WORK HISTORY				A curriculum vitae is not sufficient.
	A.	Please chronologically list and account for work, professional and practice history activities for the past three (3) years to
		present, including military service. Please explain in section B any gaps greater than two (2) months.
		Please attach additional sheets, if necessary.
Name of current practice/employer:					Contact’s name:

Telephone number:			Fax number:		Complete address:
(	)	Ext.:	(	)
From month/year:			To month/year:

Contact’s email address, if available:					Professional liability carrier:

Name of previous practice/employer:					Contact’s name:

Telephone number:			Fax number:		Complete address:
(	)	Ext.:	(	)
From month/year:			To month/year:

Contact’s email address, if available:					Professional liability carrier:

Name of previous practice/employer:					Contact’s name:

Telephone number:			Fax number:		Complete address:
(	)	Ext.:	(	)
From month / Year:			To month/year:

Contact’s email address, if available:					Professional liability carrier:

Name of previous practice/employer:					Contact’s name:

Telephone number:			Fax number:		Complete address:
(	)	Ext.:	(	)
From month/year:			To month/year:

Contact’s email address, if available:					Professional liability carrier:

Name of previous practice/employer:					Contact’s name:

Telephone number:			Fax number:		Complete address:
(	)	Ext.:	(	)
From month/year:			To month/year:

Contact’s email address, if available:					Professional liability carrier:

Name of previous practice/employer:					Contact’s name:

Telephone number:			Fax number:		Complete address:
(	)	Ext.:	(	)
From month/year:			To month/year:

Contact’s email address, if available:					Professional liability carrier:

Name of previous practice/employer:					Contact’s name:

Telephone number:			Fax number:		Complete address:
(	)	Ext.:	(	)
From month/year:			To month/year:

Contact’s email address, if available:					Professional liability carrier:

		Oregon Practitioner Recredentialing Application 5/1/12		Page 6 of 10		INITIALS:	DATE:

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Form Information

Fact Name	Fact Detail
Governing Law	The Oregon Practitioner Recredentialing Application is established under House Bill 2144 (1999).
Application Purpose	This application is used for credentialing and recredentialing practitioners in Oregon by hospitals and health plans.
Submission Requirement	Applicants must submit the completed application to the health care organization, not to the State of Oregon.
Signature Requirement	Applicants must sign and date specific pages of the application, including the Attestation Questions and Authorization and Release of Information Form.
Documentation	Current copies of state professional licenses, DEA certificates, and other documents must accompany the application.
Initials Requirement	Each page of the application requires the applicant’s initials and the date of the last review.
Optional Curriculum Vitae	A curriculum vitae is optional and not an acceptable substitute for the required information in the application.
Specialty Information	Applicants may list their principal clinical specialty and additional specialties for directory listings.
Continuing Medical Education	Applicants must list CME activities attended in the past two years, if applicable.
Practice Information	Comprehensive practice information, including primary and secondary locations, must be provided in the application.

Detailed Guide for Filling Out Oregon Practitioner Application

Completing the Oregon Practitioner Application form is essential for those seeking recredentialing. It involves providing detailed personal, professional, and educational information. Following these steps will help ensure that the application is filled out correctly and submitted without issues.

Begin by typing or neatly printing the application using black or blue ink.
Fill out all sections of the application completely. If you need more space, attach additional sheets and reference the relevant question.
Do not modify the wording or format of the application, as this will invalidate it.
Keep an unsigned and undated copy of the completed application for your records.
Indicate the health care organization(s) to which you are applying in the designated space.
Attach the required documents, including your state professional license(s), DEA or CSR certificate, and any other relevant certifications.
Sign and date page 8 (Attestation Questions) and page 9 (Authorization and Release of Information Form). If applicable, also sign Attachment A regarding Professional Liability Action Detail.
Initial and date each page of the application to indicate your review.
If any section does not apply to you, check the provided box at the top of that section.
Mail the completed application and attachments to the designated health care organization(s), not to the State of Oregon.

Obtain Answers on Oregon Practitioner Application

What is the purpose of the Oregon Practitioner Recredentialing Application?

The Oregon Practitioner Recredentialing Application is designed to facilitate the credentialing and recredentialing process for healthcare practitioners in Oregon. Established by House Bill 2144 in 1999, it is utilized by hospitals and health plans to ensure that practitioners meet the necessary qualifications to provide care. The application is developed by the Advisory Committee on Physician Credentialing Information (ACPCI).
How should I complete the application?

It is essential to complete the application in its entirety. You can type your responses or print them legibly in black or blue ink. If you require more space than provided, attach additional sheets and clearly reference the corresponding question. Modifying the wording or format of the application will invalidate it, so adhere closely to the original structure.
What documents must accompany the application?

When submitting your application, you must include current copies of the following documents:
- State Professional License(s)
- DEA Certificate or CSR Certificate
- ECFMG Certificate (if applicable)
- Face Sheet of Professional Liability Policy or Certificate
A curriculum vitae is optional and cannot substitute for these required documents.
Do I need to sign and date the application?

Yes, it is crucial to sign and date the application. Specifically, you must sign and date the Attestation Questions on page 8 and the Authorization and Release of Information Form on page 9. If applicable, you should also sign Attachment A, which pertains to Professional Liability Action Details.
What if a section of the application does not apply to me?

If a particular section is not relevant to your situation, simply check the box at the top of that section. This indicates that you have reviewed the section and confirm that it does not apply.
How do I ensure that my application is submitted correctly?

To ensure proper submission, keep an unsigned and undated copy of your completed application for your records. When sending the application, make sure to send it to the healthcare-related organization to which you are applying, not to the State of Oregon. Double-check that all information is complete, current, and accurate before mailing it.
Is there a specific format for listing my education and certifications?

Yes, when listing your education, certifications, and other qualifications, follow the specified format in the application. Include details such as the name of the institution, dates attended, and any certifications received. If you have multiple certifications or educational experiences, attach additional sheets as necessary.
What should I do if I have additional practice locations?

If you have more than one practice location, you should list the additional locations on a separate sheet, providing the same detailed information required for your primary practice. This ensures that all relevant practice information is captured.
What is the role of the Advisory Committee on Physician Credentialing Information?

The Advisory Committee on Physician Credentialing Information (ACPCI) is responsible for reviewing and approving the application forms used in the credentialing process. Their role is to ensure that the application remains uniform and meets the standards necessary for healthcare practitioners in Oregon.
What happens after I submit my application?

After submitting your application, the healthcare organization will review it along with the accompanying documents. They may reach out for additional information or clarification if needed. Once the review process is complete, you will be notified regarding your credentialing status.

Common mistakes

Filling out the Oregon Practitioner Application form can be a straightforward process, but many applicants make common mistakes that can lead to delays or even rejection. Understanding these pitfalls is crucial for a successful submission.

One frequent error is failing to read the instructions thoroughly. Applicants often overlook specific guidelines, such as the requirement to type the application or use blue or black ink. Not following these formatting rules can invalidate the application. Always ensure that you adhere to the specified instructions to avoid unnecessary complications.

Another mistake is neglecting to sign and date the necessary pages. The application requires signatures on page 8 and page 9, as well as on Attachment A, if applicable. Missing these signatures can cause the application to be considered incomplete. Double-check your document before submission to ensure all required signatures are present.

Many applicants also forget to include their initials and the date on each page of the application. This detail is not merely a formality; it confirms that the information has been reviewed and is current. Omitting this step can lead to questions about the validity of the application.

Providing outdated or incorrect information is another common error. It’s essential to ensure that all details, including addresses, contact numbers, and professional licenses, are accurate and up-to-date. Inaccuracies can raise red flags and delay the credentialing process.

Some applicants fail to attach the necessary documents, such as copies of state professional licenses and DEA certificates. Each application submission must include these documents. Neglecting to do so can result in the application being returned or delayed.

Another mistake is not checking the boxes for sections that do not apply. If a section is irrelevant to your situation, ensure you indicate that by checking the provided box. This helps clarify your application and avoids confusion.

Applicants sometimes submit the application to the wrong organization. It’s crucial to send your completed application to the specific health care organization you are applying to, not to the State of Oregon. Misaddressing your application can lead to significant delays.

Lastly, many people overlook the importance of keeping a signed and undated copy of their application. This practice not only helps in tracking your submissions but also provides a reference for future applications. Always maintain a copy for your records.

By avoiding these common mistakes, you can enhance your chances of a smooth and successful application process. Take the time to review your application carefully before submission.

Documents used along the form

When applying for the Oregon Practitioner Recredentialing Application, there are several additional forms and documents that may be required to ensure a comprehensive review of the applicant's qualifications. Each of these documents serves a specific purpose in the credentialing process, helping to verify the applicant's credentials and professional history.

State Professional License(s): This document confirms that the practitioner holds a valid license to practice in the state of Oregon. It is essential for demonstrating compliance with state regulations governing medical practice.
DEA Certificate or CSR Certificate: The Drug Enforcement Administration (DEA) certificate is necessary for practitioners who prescribe controlled substances. This certificate verifies that the practitioner is authorized to handle and prescribe these medications.
ECFMG Certification (if applicable): For international medical graduates, the Educational Commission for Foreign Medical Graduates (ECFMG) certification is required. It indicates that the practitioner has met the necessary qualifications to practice in the United States.
Face Sheet of Professional Liability Policy or Certificate: This document provides evidence of the practitioner's malpractice insurance coverage. It is crucial for assessing the practitioner's liability protection while practicing medicine.
Curriculum Vitae (optional): Although not mandatory, a curriculum vitae can provide a detailed overview of the practitioner's education, training, and professional experience. It can offer valuable context to the application.
Additional Sheets for Certifications: If the practitioner has multiple certifications beyond those listed, additional sheets may be attached to detail these qualifications, ensuring a complete representation of the practitioner's credentials.

Submitting these documents alongside the Oregon Practitioner Recredentialing Application is vital for a smooth and efficient credentialing process. Each document plays a role in verifying the practitioner's qualifications and ensuring compliance with state and federal regulations.

Similar forms

California Practitioner Application: Similar to the Oregon form, it collects detailed personal and professional information, including licensing and certifications, to ensure practitioners meet state requirements.
Washington State Credentialing Application: This document requires similar information about the practitioner's education, training, and professional history, facilitating the credentialing process for health care organizations.
Texas Medical Board Application: Like the Oregon application, it mandates comprehensive disclosure of professional liability actions and requires supporting documentation for licensure and certifications.
Florida Practitioner Credentialing Application: This form parallels the Oregon application in its structure and purpose, gathering essential information to verify a practitioner's qualifications for practice in the state.
New York State License Application: It shares similarities in requesting detailed personal and professional data, ensuring that applicants meet state-specific licensing requirements.
Illinois Medical License Application: This document is akin to the Oregon application as it requires information on education, training, and current practice details to assess eligibility for licensure.
North Carolina Medical Board Application: This application mirrors the Oregon form by requesting a thorough account of the applicant's professional background, including any disciplinary actions and certifications.

Dos and Don'ts

Things to Do When Filling Out the Oregon Practitioner Application Form:

Type the application or print it legibly in black or blue ink.
Attach additional sheets if you need more space for your answers.
Sign and date the required pages, including the Attestation Questions and Authorization and Release of Information Form.
Initial and date each page of the application.
Identify the health care organization to which you are submitting the application.
Include all requested documents, such as your State Professional License and DEA Certificate.
Mail the completed application to the requesting organization, not to the State of Oregon.

Things Not to Do When Filling Out the Oregon Practitioner Application Form:

Do not modify the wording or format of the application; this will invalidate it.
Do not leave any sections blank; if a section does not apply, check the provided box.
Do not forget to keep an unsigned and undated copy of the application for your records.
Do not submit a curriculum vitae as a substitute for the application.
Do not forget to check the accuracy and completeness of all information before sending.
Do not submit the application without the necessary attachments.
Do not ignore the instructions regarding the mailing address for submission.

Misconceptions

There are several misconceptions surrounding the Oregon Practitioner Application form that can lead to confusion during the application process. Understanding these misconceptions can help applicants navigate the requirements more effectively.

Modification of the Form is Allowed: Some applicants believe they can modify the wording or format of the Oregon Practitioner Application. However, any changes made will invalidate the application, making it crucial to use the form as is.
All Sections Must Apply: It is a common misunderstanding that every section of the application must be filled out. If a section does not apply to an applicant, they should simply check the provided box to indicate that.
A Curriculum Vitae is Mandatory: Many assume that submitting a curriculum vitae (CV) is necessary. In fact, while a CV is optional, it cannot be used as a substitute for the required information on the application.
Unsigned Applications are Acceptable: Some believe that an unsigned application can still be submitted. This is incorrect; applicants must sign and date specific pages of the application for it to be considered complete.
Submitting to the State of Oregon is Required: There is a misconception that applicants should send their completed application to the State of Oregon. Instead, the application should be returned directly to the health care organization requesting it.
Only Current Licenses are Needed: Applicants may think that only their current licenses are required. However, it is important to attach copies of all relevant documents, including any past licenses or certifications that may apply.

Key takeaways

Complete the application thoroughly. Ensure that every section is filled out completely. Incomplete applications may delay the credentialing process.
Use the correct format. Type the application or print it legibly in black or blue ink. Modifying the wording or format can invalidate your application.
Provide accurate documentation. Attach all required documents, such as your state professional license, DEA certificate, and any other requested materials, each time you submit the application.
Sign and date necessary sections. Don’t forget to sign and date the Attestation Questions and Authorization and Release of Information Form.
Keep a copy for your records. Maintain an unsigned and undated copy of your application for future reference and requests.
Submit to the correct organization. Ensure that you send the completed application to the health care organization you are applying to, not to the State of Oregon.