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)
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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)
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