OHP 3165 Waiver Form for Health Services: Signing and 30-Day Rules

The OHP 3165 form is the Oregon Health Plan’s agreement-to-pay document that a provider must have you sign before delivering any non-covered service you’ll pay for out of pocket. Without a completed, pre-signed copy of this form (or an equivalent document with the same required information), an OHP-enrolled provider cannot bill you, collect from you, or send the balance to collections for services you received while eligible for medical assistance. The form is available as a PDF from the Oregon Health Authority at sharedsystems.dhsoha.state.or.us.

When a Provider Needs This Form Signed

Oregon Administrative Rule 410-120-1280 sets out the specific billing situations where the OHP 3165 applies. The most common one is a service that OHP or your Coordinated Care Organization does not cover, including services denied through prior authorization. Before performing that service, the provider must have you sign a completed form in advance.¹

The form also applies when you ask to pay privately for a service OHP would otherwise cover. In that case the provider must first tell you in writing that OHP would pay for the service in full, give an estimate of what you’ll owe including all related charges, confirm you’re agreeing voluntarily, and give you a chance to consult your caseworker or representative before signing. The provider also cannot charge you more than what OHP would have paid.²

A third situation involves continuation of benefits during an appeal. If you asked to keep receiving a service while appealing a denial and the final decision goes against you, you owe for the services received on or after the effective date on the notice. The provider must complete and have you sign the OHP 3165 before continuing those services.¹

What Has to Be on the Form

The provider fills out the form before presenting it for your signature. The rule and the form itself require these elements:

Your full name and Oregon Health Plan identification number.
The provider’s name and National Provider Identifier (NPI).
The CPT or HCPCS code for each proposed service, with the scheduled date.
A realistic dollar estimate for each service. This figure is binding; the agreement is only valid if the actual charge matches it.
The reason OHP won’t pay, whether that’s a prior authorization denial, a service outside your benefit package, or your decision to pay privately for a covered service.

Providers aren’t locked into the exact OHP 3165 PDF. The rule allows a “facsimile containing all of the information and elements” shown in the form’s table within OAR 410-120-1280. A provider’s own form is fine so long as every required data point appears.¹

Before completing the form, the provider must verify your eligibility and benefit package under OAR 410-120-1140. The Oregon Medicaid Provider Portal at or-medicaid.gov shows up to 13 months of eligibility history, CCO enrollment, and prior authorization requirements.³

Signing Rules and the 30-Day Window

You (or your authorized representative) must sign and date the form before the service happens. A signature obtained after the fact is worthless. If the provider didn’t get your signature in advance, they cannot bill you, collect from you, or send the bill to collections.¹

A signed OHP 3165 stays valid only while two conditions hold. The estimated fee cannot change from what’s listed, and the service must be scheduled within 30 days of your signature. If the provider revises the cost estimate or the appointment slips past 30 days, they need a new signed form. One exception covers long-term services such as prenatal care and labor and delivery, where a single form can cover the full duration of the pregnancy.¹

After signing, you’re entitled to a copy of the agreement for your records. The provider keeps the original in your file and must produce it on request from the Oregon Health Authority or your CCO.

When the Form Does Not Protect the Provider

A signed OHP 3165 doesn’t override the law. Under ORS 414.066, a provider cannot bill or solicit payment from a medical assistance recipient for a covered service, regardless of what paperwork was signed. If the state confirms you were eligible and the service was covered when provided, the provider also cannot assign the bill to collections.⁴

The form also cannot be used as a condition of emergency care. Under EMTALA, any hospital with an emergency department must screen and stabilize patients regardless of insurance status or ability to pay. A provider cannot require you to sign a payment agreement before receiving emergency treatment.⁵

Several common errors make the agreement unenforceable:

Signature obtained after treatment began. Post-service signatures don’t count.
Actual charge different from the estimate on the form.
Service not scheduled within 30 days of signature (outside the long-term care exception).
Service was actually covered by OHP at the time it was provided.
Missing required disclosures when you’ve chosen to pay privately for a covered service, including the written notice that OHP would pay and the cap on what you can be charged.

If you think a provider billed you without a valid signed form, or for a service that was covered, you can report it to the Oregon Health Authority’s Office of Program Integrity.

Before You Sign, Consider Appealing the Denial

If the reason you’re being asked to sign is a coverage denial, the appeal process may eliminate the bill entirely. You have 60 days from the date on the Notice of Adverse Benefit Determination to appeal through your CCO. You, a representative, or your provider with your written permission can file. Standard appeals are decided within 16 calendar days, with a possible 14-day extension.⁶

If the situation is urgent, request an expedited appeal and include a statement from your provider explaining why. If the CCO agrees it’s urgent, it must decide within 72 hours.⁶

If you’re already receiving the denied service, you can ask to keep it going during the appeal. You must request continuation when you file and do so within 10 days of the effective date on the notice. If you lose the appeal, you’ll owe for services received during that period, and the provider will need a signed OHP 3165 before continuing care.⁶

If the CCO appeal is unsuccessful, you can request a contested case hearing through the Oregon Health Authority. Federal Medicaid rules guarantee the right to a fair hearing when a claim for services is denied, and the agency must issue a final decision within 90 days of your hearing request.⁷

Where to Download the Form

The direct PDF is at sharedsystems.dhsoha.state.or.us/DHSForms/Served/he3165.pdf. You can also search by form number through the Oregon Health Authority’s forms and publications page at oregon.gov/oha.

OHP uses three different agreement-to-pay forms depending on the service:⁸

OHP 3165 covers general health care services.
OHP 3166 covers prescription medications.
OHP 4109 covers planned community births.

Make sure you’re using the one that matches the service in question. A pharmacy charge needs the 3166, not the 3165, and signing the wrong form may leave the agreement unenforceable on the same grounds as missing required information.

1
Oregon Secretary of State. Oregon Administrative Rule 410-120-1280 – Billing
2
Legal Information Institute. Oregon Administrative Code 410-120-1280 – Billing
3
Oregon Health Authority. Oregon Health Plan Eligibility Verification
4
Oregon State Legislature. Oregon Revised Statutes 414.066 – Billing Patient for Services Covered by Medical Assistance Prohibited
5
Centers for Medicare & Medicaid Services. Emergency Medical Treatment & Labor Act (EMTALA)
6
Oregon Health Authority. Oregon Health Plan (OHP) Appeals and Hearings
7
eCFR. Fair Hearings for Applicants and Beneficiaries
8
Oregon Health Authority. Services That Are Limited or Not Covered by the Oregon Health Plan