Provider Enrollment Attachment
To be completed by Renal Dialysis Providers only
(Provider Name and Location for this Enrollment)
(Date)
In order to enroll as a Renal Dialysis provider for Oregon Medicaid, you must complete
this attachment and return it (along with copies of the 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)
Billing Information
Who will be billing for your services?
Hospital
If you checked “Hospital” and you perform your services only in a
Hospital setting and are paid/salaried by the Hospital, stop here.
 You do not need to enroll with OHA in order to be paid for your
services provided in a hospital setting. The Hospital will be paid for
your services. Do not send in any enrollment forms to OHA.
Facility
Group
(Billing
Provider)
If you checked “Facility,” complete this attachment and other
required documents listed above.
 Do not send in the DMAP 3117 (Facility Attachment).
If you checked “Group (Billing Provider),” complete this
attachment, the other required documents listed above, and the DMAP
3110 (Billing Provider Attachment).
Identifying Information
1.
Providers located within the State of Oregon must be licensed by OHA as an
outpatient renal dialysis facility (attach copy).
2.
Enter this facility’s CLIA number here and attach a copy of your current CLIA
Certification letter:
3.
List any current or previous OHA Provider Numbers here:
4.
List any names/business names currently or previously used with DMAP or other
Oregon Health Authority (OHA) contracts:
Provider Enrollment Attachment – Dialysis Facility
DMAP 3109 (Rev. 07/11)
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5.
Is the facility 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):
8
Is the clinic or facility Medicare-eligible?
If Yes, attach a copy of the Medicare enrollment letter.
9
Enter the facility’s Fiscal Year end date (month and day):
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
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 Dialysis Providers 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
your facility is located that can confirm your Medicaid enrollment in that state:
Medicaid Office Name
2.
Phone Number
Attach a copy of all licenses and certificates showing authority to operate as a
dialysis facility for the state in which your practice is located.
Provider Enrollment Attachment – Dialysis Facility
DMAP 3109 (Rev. 07/11)
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