DIVISION OF MEDICAL ASSISTANCE PROGRAMS
Provider Enrollment Unit
(Provider Name and Location for this Enrollment) (Date)
In order to enroll as a Facility Provider with Oregon Medicaid, you must complete this attachment and return it with the following information:

Completed OHA 3972 (Provider Enrollment Request)

Signed and dated OHA 3974 (Disclosure Statement of Ownership and Control Interest)

Signed and dated OHA 3975 (Provider Enrollment Agreement)

Copy of current license(s), certificates and other information requested below
1. Enter your current business/facility license number below and attach a copy of all licenses and certificates showing authority to operate the facility provider type identified above for the state in which your facility is located.
License/Registration Number (attach copy) Mo/Day/Year of Expiration
2. List any current or previous Oregon Medicaid provider numbers here:
3. List any names/business names currently or previously used with DMAP or other Oregon
Health Authority (OHA) contracts:
4. Is the facility owned by a unit of government when providing these services? Check any government type that applies to this provider.
County Public school district
State
Publicly operated teaching hospital
Special purpose district Tribal
Other governmental unit (specify):
5. Are services provided in a private school setting? Yes No
Provider Enrollment Attachment – ABA Organizations DMAP 3117 ABA (Rev. 06/15)
Page 1 of 2

6. List the general and 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 facilities 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 – ABA Organizations DMAP 3117 ABA (Rev. 06/15)
Page 2 of 2