DIVISION OF MEDICAL ASSISTANCE PROGRAMS
Provider Enrollment Unit
Provider Enrollment Information
Complete all applicable information.
Individual provider information
1.
Last name:
First name:
2.
Date of Birth (DOB):
3.
Social Security Number (SSN):
4.
Title/Degree (as appears on license):
5.
IRS Tax ID Type (for reporting purposes for payment; check one): This information must
match IRS’s information on file.
SSN
6.
Middle initial:
DOB
Group Practice: If you are applying to join an existing group, enter the group’s NPI(s).
Group/facility information
1.
Group/Facility Name:
2.
Doing Business As (DBA) Name:
3.
Business IRS Tax ID (for reporting purposes for payment): This information must match
IRS’s information on file.
Business name associated with IRS FEIN:
FEIN
Enrollment information
1.
Business type (check all that apply):
Individual Practitioner
Chain
Trust
Sole Proprietorship
Government
LLC
Partnership
Intergovernmental
LLP
Business Corporation:
For profit
Non-Profit
2.
Private:
For profit
Non-Profit
Are you applying as a (select one):
Individual
Provider Enrollment Information
Group
Facility
Organization
OHA 3972 (Rev. 8/14)
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3.
4.
5.
Identification Numbers:
DEA Number:
EFT Number:
NPI:
NABP Number:
CDS (Controlled Dangerous Substance) Number:
Provider Type: Select the provider type you are requesting enrollment as.
01 Transportation Provider
32 End-Stage Renal Disease
Clinic
66 Urban Clinic
02 Acupuncturist
33 Mental Health Provider
69 Social Worker
03 Alcohol/Drug
34 Physician
70 Foster Care
05 Ambulatory Surgical Provider
35 Oregon State Hospital
71 Child Foster Care
06 Behavioral Rehab Specialist
36 DME/Medical Supply Dealer
72 SPD Transportation
07 Billing Service
37 Certified Registered Nurse
Anesthetist
73 Home Care Worker
08 Freestanding Birthing Center
38 Advanced Comprehensive
Health Care (Naturopath)
74 Client Support Services
09 Billing Provider/Group Clinic
41 Midwife
75 Case Management
10 Transportation Broker
42 Advance Practice Nurse
76 County Services
12 Copy Services
43 Optometrist
77 Adaptive Modification
13 Cost Based Clinic
44 Optician
78 Habilitation
14 Rural Health Clinic
45 Therapist
80 Intermediate Care
Facility/Mental Retardation
15 FQHC
46 Physician Assistants
81 Nursing Facility
16 Chiropractor
47 Clinic
82 SPD Nutritionist
17 Dentist
48 Pharmacy
83 Behavioral Consultant
18 Dental Hygienist
49 Prenatal Clinic
84 Personal Assistant
19 Podiatrist
50 Pharmacist
86 SPD Nursing Services
20 Denturist
52 X-Ray Clinic
88 Nursing Agency
21 Enteral/Parenteral
53 Psychologist Provider
89 DD Living Facilities
22 Family Planning Clinic
54 Polygrapher
97 Residential Contract Rates
23 Hearing Aid Dealer
56 Registered Nurse
90 APD Living Residential
24 Home Health Agency
57 RN 1st Assistant
91 APD Living Settings
26 Hospital
58 Registered Dietician
92 Emergency Response (Lifeline)
27 Hospice
60 Smoking Cessation
93 In Home Care Agency
28 Indian Health Clinics
62 Education Agency
29 Independent Labs
64 Targeted Case Management
30 Mental Health Personal Care
Attendant
65 Translator
Specialty Information: List below. If you have additional specialty/taxonomies, please list on an
attachment (maximum allowed is 15).
Provider Enrollment Information
OHA 3972 (Rev. 8/14)
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Primary Specialty:
6.
7.
Taxonomy:
Sub-Specialty:
Taxonomy:
Effective Date:
End Date:
Sub-Specialty:
Taxonomy:
Effective Date:
End Date:
Sub-Specialty:
Taxonomy:
Effective Date:
End Date:
Sub-Specialty:
Taxonomy:
Effective Date:
End Date:
Sub-Specialty:
Taxonomy:
Effective Date:
End Date:
License/Certification Information:
License Number:
License Type:
Certification:
Begin Date:
End Date:
State:
Are you an active Medicare Provider? If Yes, please indicate your Medicare
Provider ID number.
Yes
No
Medicare Provider ID number:
8.
Are you an active Medicaid Provider in another state? If Yes, please indicate your
Medicaid Provider ID number, state and contact information.
Other State Medicaid Provider ID
State Contact Name
9a.
Yes
No
State of Issue
Email
Phone Number
Provider address 1. Complete all applicable information. Note: A post office box is not a valid
service location; the service location address must be a physical street address.
Street or PO Box (include Room/Suite):
City, State, ZIP:
County:
Business Phone:
Toll-Free Phone:
Fax Number:
Cell Phone:
E-mail:
International Phone:
International Fax:
ADA Accessible?
Yes
No
Contact Name:
Contact SSN:
Contact Title:
Contact Type:
Contact E-mail:
Provider Enrollment Information
Contact Phone Number:
Information applies to
(check all that apply):
Service Location
Pay-To
Mail-To
Home Office
Corporate Office
Medical Information
Personal Residence
Contact DOB:
Contact E-mail:
OHA 3972 (Rev. 8/14)
Page 3 of 4
Contact Fax Number:
9b.
Contact Effective Date:
Contact Fax Number:
If this information applies to more than one service location, list the service locations here:
10a. Provider address 2. Complete all applicable information. If you need to provide more than two
addresses, please list on an attachment. Note: A post office box is not a valid service location;
the service location address must be a physical street address.
Street or PO Box (include Room/Suite):
City, State, ZIP:
Information applies to
(check all that apply):
County:
Business Phone:
Toll-Free Phone:
Fax Number:
Cell Phone:
E-mail:
International Phone:
International Fax:
ADA Accessible?
Yes
No
Contact Name:
Contact SSN:
Contact Title:
Contact Type:
Service Location
Pay-To
Mail-To
Home Office
Corporate Office
Medical Information
Personal Residence
Contact DOB:
Contact E-mail:
Contact Phone Number:
Contact Cell Phone:
Contact Fax Number:
Contact Effective Date:
Contact End Date:
10b. If this information applies to more than one service location, list the service locations here:
Internal Use Only: ATN
Provider Enrollment Information
OHA 3972 (Rev. 8/14)
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