Provider Enrollment Attachment
To be completed by Retail and Institutional Pharmacy Providers only
(Provider Name and Location for this Enrollment)
This attachment is for enrollment as:
Institutional Pharmacy (complete pages 1-3)
(Date)
Retail Pharmacy (complete pages 1-2)
In order to enroll as a Retail or Institutional Pharmacy provider with Oregon Medicaid, you
must complete this attachment and return it (along with copies of information requested) with
the following information:
 Completed DHS 3972 (Provider Enrollment Request)
 Signed and dated DHS 3974 (Disclosure Statement of Ownership and Control
Interest)
 Signed and dated DHS 3975 (Provider Enrollment Agreement)
Identifying Information
1.
Enter your retail or institutional Oregon Board of Pharmacy license number for the
pharmacy type checked and attach a copy of your current license:
2.
Enter your National Association of Board of Pharmacy number:
3.
Enter your (DEA) Drug Enforcement Agency number (if applicable):
4.
Are you a mail order pharmacy that needs to coordinate benefits for a DMAP client?
Yes
No
4a. If Yes, enter the DMAP patient ID number to be coordinated:
4b. If No, continue to the next question. We are not able to enroll mail order pharmacies at
this time.
5. Does your pharmacy dispense 340B drugs?
Yes
No
5a. If Yes, provide your 340B identification number and attach a copy of your 340B
registration form:
5b. If Yes, provide documentation of your processes to ensure billing Oregon Medicaid
that is separate from billing for 340B.
6. Choose your pharmacy type:
Independent Pharmacy
Chain Pharmacy (Oregon defines a chain as 11 or more pharmacies under common
ownership)
Provider Enrollment Attachment – Retail or Institutional Pharmacy
DMAP 3115 (Rev. 10/11)
Page 1 of 3
7.
List any names/business names currently or previously used with DMAP or other
Oregon Health Authority (OHA) contracts:
8.
Is the pharmacy owned or operated by a unit of government? Check any government
type that applies to this provider.
County
School district
Transportation district
State
Special purpose district
Tribal
Publicly operated
teaching hospital
Other governmental unit (specify):
Insurance Information
1.
List the general and professional liability insurance information you have, will maintain
and will provide upon request by OHA or a OHA designee. This is to cover damages
caused by error, omission or negligent acts related to the professional services to be
provided as an Oregon Medicaid provider.
If you cancel, materially change, reduce limits, or intend not to renew the insurance
coverage(s) listed below, you must notify DMAP within 30 days of the change:
Carrier Name
2.
Policy Number
Expiration Date
Amount insured per
occurrence
If you are self-insured for these insurance requirements, enter “Self-Insured” here:
Out-of-State Providers only:
In addition to the information requested above, provide the following information:
1.
Do you have a license to dispense medications in Oregon from the Oregon Board of
Pharmacy?
Yes
No
1a. If Yes, enter your Oregon State Board of Pharmacy License number:
1b. If No, please contact the Oregon Board of Pharmacy for information.
2.
Enter the name and telephone number of the Medicaid office in the state in which your
pharmacy is located that can confirm your Medicaid enrollment in that state:
Provider Enrollment Attachment – Retail or Institutional Pharmacy
DMAP 3115 (Rev. 10/11)
Page 2 of 3
Medicaid Office Name
3.
Phone Number
Attach a copy of all licenses and certificates (including a copy of your current CLIA
certificate, if applicable) showing authority to operate the pharmacy identified above
for the state in which the provider is located.
Institutional Pharmacy Providers Only:
This section must be completed and returned with your enrollment forms in order to be
enrolled as an Institutional Pharmacy Provider for Oregon Medicaid.
1. Complete the following information:
3.
Pharmacy Name
NPI
Address
City
Telephone Number
Fax Number
Taxonomy
ZIP
Supervising Pharmacist:
Institutional Pharmacy Signature: I hereby certify the above information is true and
correct to the best of my knowledge.
Signature of preparer
Title
Date
Print or type name
Provider Enrollment Attachment – Retail or Institutional Pharmacy
DMAP 3115 (Rev. 10/11)
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