DIVISION OF MEDICAL ASSISTANCE PROGRAMS
Provider Enrollment Unit
Provider Enrollment Attachment
To be completed by Substance Use Disorder Programs only
(Provider Name and Location for this Enrollment)
(Date)
In order to enroll as a Substance Use Disorder Program with Oregon Medicaid, you must complete
this attachment and return it with the following information:
 Completed OHA 3972 (Provider Enrollment Request)
 Signed and dated OHA 3974 (Disclosure Statement of Ownership and Control Interest)
 Signed and dated OHA 3975 (Provider Enrollment Agreement)
 Copy of current license(s), certificates and other information requested below
1.
Oregon Medicaid provider type (select one): This attachment only applies to the following
types of providers.
03 – Acupuncture Clinic
03 – Inpatient Treatment Program
03 – Detoxification Program
03 – Outpatient Treatment Program
03 – DUII Information Program
03 – Residential Treatment Program - Children
03 – DUII Rehabilitation Program
03 – Synthetic Opiate Treatment Program
03 – Evaluation Program
2.
Enter your current business/facility license number below and attach a copy of all licenses
and certificates showing authority to operate the program listed above for the state in which
your program is located. This includes letters of approval or certification issued by the
Oregon Health Authority’s Addictions and Mental Health Division (AMH).
License/Registration Number (attach copy)
Mo/Day/Year of Expiration
3.
Enter your laboratory’s CLIA number and attach a copy of your current CLIA Certification
letter:
4.
If your program contracts for laboratory services, complete the following and attach a copy
of the certification letter:
Laboratory Name:
5.
Laboratory’s CLIA number:
List any current or previous Oregon Medicaid provider numbers here:
Provider Enrollment Attachment – Substance Use Disorder Program
DMAP 3119 (Rev. 07/14)
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6.
List any names/business names currently or previously used with DMAP or other Oregon
Health Authority (OHA) contracts:
7.
Is the Substance Use Disorder Program 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
City
Publicly operated teaching hospital
Other governmental unit (specify):
8.
If applicable, list your rates here and attach a copy of your fee schedule:
9.
List the general and professional liability insurance information you have, will maintain, and
will provide upon request by OHA or an 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
Expiration Date
Amount insured per occurrence
10.
If you are self-insured for these insurance requirements, enter “Self-Insured” here:
11.
Do you exclusively employ licensed staff?
If yes, attach a copy of a staff list that includes their credentials.
Yes
No
12.
If you decide to hire unlicensed staff, do you acknowledge that you will
seek AMH certification?
Yes
No
13.
If you employ unlicensed staff, are you certified by AMH in accordance
with OAR 309-012 and 415-012? If you have questions about the
certification process, call 503-945-7818 (Salem).
Yes
No
14.
Tell us whom you contract with (check all that apply):
15.
AMH
County Mental Health Program
Coordinated Care Organization
Mental Health Organization
Out of state programs only: Enter the name and telephone number of the Medicaid office
in your state that can confirm your Medicaid enrollment in that state:
Medicaid Office Name
Phone Number
Provider Enrollment Attachment – Substance Use Disorder Program
DMAP 3119 (Rev. 07/14)
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