Provider Enrollment Attachment
To be completed by Independent Radiology Providers only
(Provider Name and Location for this Enrollment)
(Date)
In order to enroll as an Independent Radiology provider with 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 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
If you checked “Facility,” complete this attachment and other
required documents listed above.
 Do not send in the DMAP 3117 (Facility Attachment).
Group
If you checked “Group (Billing Provider),” complete this
(Billing
attachment, the other required documents listed above, and the
Provider)
DMAP 3110 (Billing Provider Attachment).
Identifying Information
1.
For radiology providers located in Oregon, enter the license number issued by
the Oregon Health Authority on the line below and attach a copy of your current
license:
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:
Provider Enrollment Attachment – Independent Radiology
DMAP 3105 (Rev. 07/11)
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4.
List any names/business names currently or previously used with DMAP or other
Oregon Health Authority (OHA) contract:
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):
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 Radiology Facilities 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 the
facility identified above for the state in which the facility is located.
Provider Enrollment Attachment – Independent Radiology
DMAP 3105 (Rev. 07/11)
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