Oregon Medicaid Electronic Data Interchange Trading Partner Agreement OHA 2080 (Rev 7/17) Page 1 of 2
HEALTH SYSTEMS DIVISION
EDI Support Services
Trading Partner’s National Provider Identifier (NPI):
List all taxonomy code(s) registered to this NPI:
List the Oregon Medicaid ID(s) associated with this NPI:
Trading Partner Agreement for Electronic Health Care Transactions
When to complete this form: Trading partners must complete and submit this form to:
• Sign up to exchange transactions with the Oregon Health Authority (OHA).
• Authorize who will exchange these transactions for you.
• Make any changes to trading partner or submitter information on file with OHA.
How to complete this form:
• If you need to exchange transactions for more than one NPI, complete a TPA for each NPI.
• If you need to exchange transactions for multiple Oregon Medicaid ID numbers, y
ou can use one
TPA but only if all locations need the same transactions.
• If you need to authorize more than one clearinghouse/submitter, complete a TPA for each one.
• Please type or print clearly. Fill in all required fields designated with an asterisk (*). Incomplete
forms will NOT be processed.
• Please maintain a copy for your records.
• Mail the completed form to: EDI Support Services, 500 Summer St NE, E44, Salem, OR 97301.
Questions? Email DHS.EDISupport@state.or.us.
This TPA (select one): Fully replaces the current TPA on file. This TPA will end all previous
provider/submitter combinations registered under your Oregon Medicaid ID.
Adds information to the current TPA(s).
ONE
Trading partner information
This cannot be a billing service.
*Type (select one): Provider Clinic Coordinated Care or Managed Care Organization
*Business name (as enrolled with OHA):
Physical address:
City, state and ZIP:
Phone number/extension:
TWO
Trading partner authorized signer information
The primary signer signs Part 7 of this form.
*Primary signer’s name:
*Phone number/extension: *Title:
*Email address (direct, not group, email):
Secondary signer’s name:
Phone number/extension: Title:
Email address (direct, not group, email):
THREE
Claims contact information
This contact must be a person, not a group.
*Primary contact’s name:
*Phone number/extension: *Email address:
Secondary contact’s name:
Phone number/extension: *Email address:
FOUR
EDI submitter information
If your company intends to exchange transactions directly with OHA,
enter “Self” as the submitter name, and enter your company’s EDI contact information. If your company
intends to use a submitter/clearinghouse, complete this section for the submitter/clearinghouse.
Submitter name:
Address:
City, state and ZIP:
Submitter mailbox # :
MB000
Office Ally
PO Box 872020
Vancouver, WA 98687
329
