Provider Enrollment Attachment Hospital
To be completed by Hospital Providers only
(Provider Name and Location for this Enrollment)
(Date)
In order to enroll as a Hospital provider, 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 current hospital license number here and attach a copy of your current
hospital license:
2.
If the hospital is accredited by the Joint Commission on Accreditation of Healthcare
Organizations or the American Osteopathic Association, provide the certificate
number (attach copy):
3.
Enter this facility’s CLIA number here and attach a copy of your current CLIA
Certification letter:
4.
List any current or previous OHA Provider Numbers here:
5.
List any names/business names currently or previously used with DMAP or other
Oregon Health Authority (OHA) contracts:
6.
Check the box that best describes your hospital:
Government owned and operated
(select one):
State
Privately owned and operated
(select private entity status below):
Publicly operated
teaching hospital
Profit
County
Special purpose district
Non-profit
City
Tribal
Religious
Other governmental unit (specify):
8
Is the hospital Medicare-eligible?
If Yes, attach a copy of the Medicare enrollment letter.
Provider Enrollment Attachment
Yes
No
DMAP 3111 (Rev. 11/11)
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9
Enter the hospital’s Fiscal Year end date (month and day):
10. Check the box for the type of service(s), and list approximate number of beds per
category. Please explain when “Other” is indicated on the line below.
Type of Bed
Number of Beds
General/Acute
Swing
Physical Rehabilitation
Long-Term
Psychiatric
Drug/Alcohol Abuse Treatment
Other (specify):
11. Check all that apply:
50 or fewer beds and:
50 or more beds and:
Within 30 miles of another acute inpatient
care facility.
More than 30 miles from another acute
inpatient care facility.
Within 75 miles of the Oregon border.
More than 75 miles from the Oregon
border.
12. Does the hospital have a dedicated emergency department for purposes of the
Emergency Medical Treatment and Labor Act (EMTALA)?
Yes
No
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
Policy Number
Provider Enrollment Attachment
Expiration Date
Amount insured per
occurrence
DMAP 3111 (Rev. 11/11)
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2.
If you are self-insured for these insurance requirements, enter “Self-Insured” here:
Out-of-State Hospitals only:
In addition to the information requested above, provide the following information:
1. Enter the name and telephone number of the Medicaid office in the state in which
the hospital is located that can confirm your Medicaid enrollment in that state:
Medicaid Office Name
Phone Number
2.
Attach a copy of all licenses and certificates showing authority to operate the
hospital type identified above for the state in which your practice is located.
3.
A claim is required to include with your enrollment form (attach claim).
Provider Enrollment Attachment
DMAP 3111 (Rev. 11/11)
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