DIVISION OF MEDICAL ASSISTANCE PROGRAMS
Provider Enrollment Unit
Provider Enrollment Attachment
to be completed by Health Care Professionals only
(Provider Name and Location for this Enrollment)
(Date)
In order to enroll as a Health Care Professional with Oregon Medicaid and seek direct reimbursement
from DMAP, you must complete this attachment and return it with the following information:
 Completed OHA 3972 (Provider Enrollment Request)
 Signed and dated OHA 3973 (Disclosure Statement for Individuals)
 Signed and dated OHA 3975 (Provider Enrollment Agreement)
 Copy of current license(s) and certificates requested below
If you are employed by a clinic, group or other facility that bills on your behalf, you do not need
to complete this form. Instead, complete the DMAP 3113 (Non-Payable Provider Form) only.
1.
Oregon Medicaid provider type (select one). Behavioral health practitioners are professionals
seeking reimbursement for behavioral health care services. For psychologists and social workers
seeking reimbursement for exams/reports requested by DHS/OYA, select type 53 or 69.
02 – Acupuncturist
45 – Occupational Therapist
45 – Audiologist
17 – Oral Surgeon (Dental)
33 – Behavioral Health Practitioner. Select subtype:
34 – Oral Surgeon (Medical)
50 – Pharmacist. Select subtype:
Community Habilitation employee
LCSW
LFMT
Psychiatrist
LPC
PMHNP
Psychologist
16 – Chiropractor
ACBR-certified
Medication therapy management
Hormonal birth control prescriber
45 – Physical Therapist
34 – Physician (MD or DO)
44 – Dispensing Optician
46 – Physician Assistant
69 – Licensed Clinical Social Worker (for exams/reports)
19 – Podiatrist
86 – LTC Nursing Services
53 – Psychologist (for exams/reports)
21 – Medical Electrolysis Provider
58 – Registered Dietician
38 – Naturopath
57 – RN First Assistant
37 – Nurse Anesthetist
45 – Speech and Hearing Therapist
42 – Nurse Practitioner (Advance Practice Nurse)
45 – Speech-Language Pathologist
43 – Optometrist
2.
Enter all current and previous licensure, registration, certificates and ID numbers, with expiration
dates. If the license, certificate or registration was surrendered or not renewed, explain the reason.
Provider Enrollment Attachment – Health Care Professional
DMAP 3114 (Rev. 1/16)
Page 1 of 2
Attach a copy of current license(s) and certificates showing authority to practice for the state in
which your practice is located.
Licensure
Type
State/Country
Expiration/
Surrender Date
ID number
Reason, if surrendered or
not renewed
3.
List any current or previous Oregon Medicaid provider numbers:
4.
List any names/business names currently or previously used with DMAP or other Oregon Health
Authority (OHA) contracts:
5.
Are you employed by a unit of government when providing these services? Check any
government type that applies to this provider.
County
State
Publicly operated teaching hospital
Transportation district
School district
Tribal
Special purpose district
Other governmental unit (specify):
6. List the professional liability insurance information you have, will maintain, and will provide upon
request by OHA or an 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
Policy Number
Expiration Date
Amount insured per
occurrence
7. If you are self-insured for these insurance requirements, enter “Self-Insured” here:
8. Out-of-state providers only: Enter the name and telephone number of the Medicaid office in
your state that can confirm your Medicaid enrollment in that state:
Medicaid Office Name
Phone Number
Provider Enrollment Attachment – Health Care Professional
DMAP 3114 (Rev. 1/16)
Page 2 of 2