Provider Enrollment Attachment To be completed by Sex Offender Polygrapher Examiner Specialist Providers only (Provider Name and Location for this Enrollment) (Date) In order to enroll as a Sex Offender Polygrapher Examiner Specialist for 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 3973 (Disclosure Statement for Individuals) Signed and dated DHS 3975 (Provider Enrollment Agreement) Identifying Information 1. A Sex Offender Polygrapher Examiner Specialist must hold a license to practice polygraphy, or hold an intern license to practice polygraphy, issued by the Oregon Board of Public Standards and Training. Enter your license number and expiration/renewal date (attach copy). Intern license holders must be in training under the supervision of a Licensed Polygrapher Examiner. License Number: 2. Expiration/Renewal Date: A Sex Offender Polygrapher Examiner Specialist must have a general working knowledge of sex offenders, victims, treatment techniques, and ethical obligations as evidenced by (select one): Participation and successful completion of an approved training offered by Oregon Adolescent Sex Offender Treatment Network (attach certificate of completion); or Participation in an approved training pertaining to the treatment of sex offenders (attach documentation of attendance and successful completion); or A letter from a licensed therapist or counselor who provides treatment to sex offenders, attesting to your knowledge as described above (attach copy). 3. List any names/business names currently or previously used with DMAP or other Oregon Health Authority (OHA) contracts: Provider Enrollment Attachment – Sex Offender Polygrapher DMAP 3107 (Rev. 07/11) Page 1 of 2 5. Are you employed by a unit of government when providing these services? 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 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. Enter the name and telephone number of the Medicaid office in the state in which the provider 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 in Oregon and in the state where the provider is located. Provider Enrollment Attachment – Sex Offender Polygrapher DMAP 3107 (Rev. 07/11) Page 2 of 2