How to Complete OHP Form 3165: Agreement to Pay for Health Services

Oregon Health Plan Form 3165, the “Client Agreement to Pay for Health Services,” is the document an OHP provider and member complete before the provider delivers a service that OHP will not pay for. Without a fully completed and signed 3165 on file, an enrolled provider cannot bill the member, collect payment, or send the account to collections.¹ The form captures the specific service, the estimated cost, and the member’s written acknowledgment that OHP will not cover it, and it is only valid if the service is scheduled within 30 days of the signature.

When the Form Is Required

Oregon Revised Statutes 414.066 bars OHP providers from billing a medical assistance recipient for anything beyond copayments authorized by rule.² Oregon Administrative Rule 410-120-1280 carves out the narrow situations where a member can be billed, and in each of them a signed 3165 is the prerequisite.¹ The common triggers:

The service falls below the funding line on Oregon’s Prioritized List of Health Services. Lines 1–470 are funded through December 31, 2026; treatments ranked below line 470 are generally not covered.³
A Coordinated Care Organization denied prior authorization, which classifies the service as non-covered.
The member specifically requests a treatment that does not meet OHP criteria.
The member chooses to pay privately for a service that OHP or the CCO would otherwise pay in full. The provider must first tell the member the service is covered and that the member is opting out of OHP payment.
A member received continued benefits during an appeal and then lost the hearing. The member owes for services received on or after the effective date of the notice, and further services in that category require a new 3165.¹

A few boundaries matter. Children and youth under 21 are entitled to all medically necessary services through the Early and Periodic Screening, Diagnostic, and Treatment program, even when a service sits below the funding line, so a 3165 should not appear for a service EPSDT would cover.³ In an emergency, federal law under 42 U.S.C. § 1395dd prohibits hospitals from delaying screening or stabilizing treatment to discuss payment, so a 3165 should never be presented before the emergency is resolved.⁴ And the form cannot be used to shift the cost of a service that is actually covered: under 42 CFR § 447.15, Medicaid providers must accept the state’s payment as payment in full for covered services.⁵

For prescriptions, the companion form is OHP 3166, not the 3165.⁶

Filling Out the Provider Section

The provider completes the top half before the member sees the form. Every field must be filled in. A partial form is not a valid agreement under OAR 410-120-1280(5)(h), and an incomplete 3165 leaves the provider with no legal basis to bill.¹

Provider Type and Service Information

Check the box identifying the provider type: rendering provider, prescribing provider, hospital, pharmacy, or ancillary (other) provider. Enter the service codes using the correct system for the service, whether CDT, CPT, HCPCS, or NDC. Describe the condition being treated and list the expected dates of service. For care that extends over several months, such as pregnancy care, enter the frequency and the beginning and expected end dates instead of a single date.

Estimated Fees

Enter the estimated fee as a range using the form’s “$ to $” format. Then check one of the two fee statements. The first says no other costs are part of the service. The second warns the member that additional costs may apply and asks you to check which categories: lab work, X-rays, hospital charges, anesthesia, or other. This section carries real weight. The agreement is only valid while the estimated fee holds; if the final bill exceeds what you wrote down, the form no longer protects your ability to collect.

Provider Attestation

The rendering or prescribing provider attests to three things: that reasonable covered treatments for the condition have been tried, that the proposed service has been verified as not covered, and that the member was informed of covered alternatives and chose the non-covered option anyway. A hospital or ancillary provider completing the form uses a separate attestation acknowledging that the treating provider has already discussed alternatives with the member or directs the member to that discussion. Finish by printing your name, entering your NPI, signing, and dating.

Filling Out the Client Section

The bottom half belongs to the member. Enter the member’s full name, date of birth, and OHP Client ID number.

By signing, the member is acknowledging four things:

The listed services are not covered by OHP, the CCO, or the managed care plan.
If the member proceeds, they agree to pay and will receive bills they are obligated to pay.
The member has read the back of the form and understands other available options.
The provider has fully informed the member of all medically appropriate treatments, including any that OHP or the CCO would pay for, and the member still chooses the non-covered service.

The member signs and dates. If someone signs on the member’s behalf, such as a legal guardian, a person holding a power of attorney, or a parent signing for a minor, the representative’s printed name goes on the designated line. A witness must also sign, date, and print their name.

One practical note on comprehension: Section 1557 of the Affordable Care Act requires covered health care entities to provide meaningful access for people with limited English proficiency, including free interpretation and translated materials.⁷ A signature obtained without the member understanding the form is unlikely to hold up if the bill is later challenged.

The 30-Day Window and the Fee Rule

A completed 3165 expires if the service is not scheduled within 30 days of the member’s signature. It also becomes invalid if the estimated fee changes from what was written on the form.¹ If either happens, the provider has to complete a new form and get a fresh signature before delivering the service.

There is one carve-out. For care that naturally extends over many months, with labor and delivery given as the rule’s example, a single 3165 can cover the full duration. For anything schedulable within a normal timeframe, the 30-day clock is firm.

Where to Get the Form

The 3165 is available as a PDF through the Oregon Health Authority’s provider enrollment and forms pages.⁶ The rule allows providers to use a facsimile, meaning a self-created version, as long as it contains every element and piece of information found on the official form.¹ A form missing even one required attestation or field does not qualify.

Copies and Record Keeping

After the member signs, give the member a complete copy. Keep the original in the member’s clinical record and make it available to the Oregon Health Authority or the CCO on request.¹ Clinical records must be retained for at least ten years after the date of service, and longer if an audit, litigation, or evaluation starts before the ten years are up.⁸ The signed 3165 falls under that same retention requirement as part of the clinical record.

If You’re the Member and You Don’t Want to Sign

Being handed a 3165 does not obligate you to sign it. If the service was denied because your CCO turned down prior authorization and you believe it should be covered, you can appeal the adverse benefit determination. The CCO is required to reach out so you know your appeal rights, and your provider can file on your behalf with your written consent.⁹ You can also request a continuation of benefits during the appeal so treatment is not interrupted, but be aware that if the final decision goes against you, you will owe for services received during that period and a 3165 will need to be completed for anything further.¹

Read the back of the form before you sign. Once you sign and the service is delivered, the obligation to pay sticks.

1
Oregon Public Law. Oregon Administrative Rule 410-120-1280 – Billing
2
Oregon Public Law. Oregon Revised Statutes 414.066 – Billing Patient for Services Covered by Medical Assistance Prohibited
3
Oregon Health Authority. Prioritized List of Health Services
4
Office of the Law Revision Counsel. 42 USC 1395dd – Examination and Treatment for Emergency Medical Conditions and Women in Labor
5
eCFR. 42 CFR Part 447 – Payments for Services
6
Oregon Health Authority. Services That Are Limited or Not Covered by the Oregon Health Plan
7
U.S. Department of Health and Human Services. Language Access Provisions of the Final Rule Implementing Section 1557 of the Affordable Care Act
8
Oregon Public Law. Oregon Administrative Rules 410-141-3520 – Record Keeping and Use of Health Information Technology
9
Oregon Health Authority. Handling of Requests for Prior Authorization Including During Appeal and Hearing