Substance Use Disorder Residential Treatment
Admission/Discharge Notification Form
Substance Use Disorder Residential Programs: Use this form to report
when Oregon Health Plan clients enter or exit your program.
DIVISION OF MEDICAL ASSISTANCE
PROGRAMS
Send the completed form via secure e-mail to DMAP Client Enrollment
Services (CES) at ces.dmap@state.or.us.
CONFIDENTIALITY NOTICE: This document contains information which is confidential and/or legally privileged.
The information is intended only for the use of the individual or entity named above. If you are not the intended
recipient, you are hereby notified that any disclosure, copying, distribution or taking of any action in reliance on the
contents of this information is strictly prohibited. If you have received this document in error, please immediately
notify us via secure e-mail at ces.dmap@state.or.us and destroy the documents received. Thank you.
Client information
1 Client Name
3 Home Address
4 City State ZIP
6 Does this client have accompanying dependent child(ren)?
If yes, enter the dependent child(ren)’s name(s):
2 Client ID
5 Home County
Yes
No
Notification information
1 Type of Notification (check one):
Adult admission
Adolescent admission
Discharge
2 Contact Person Name and Phone Number
3 Name and Phone Number of person who completed this form (if different from Contact Person):
Program information
1 Licensed Program Name:
2 Treatment Program Name and Address:
3 Treatment Program City State ZIP:
4 Provider Billing ID
5 Program capacity exceeds 16 beds?
Yes
No
Admissions information – Report all admissions within 3 days of admission.
Do not bill DMAP or the CCO/MCO for newly admitted clients until DMAP CES confirms that they have
processed your admission notification form. CES will notify you via secure email when this happens.
1 Date of Admission
2 First Date of Service
3 Projected duration of stay (e.g., 90 days)
4 Current physical health enrollment (check one):
CCO
MCO
FFS
If enrolled in a CCO/MCO, enter CCO/MCO name:
5 Did you notify the CCO/MCO about this admission?
Yes
No If no, please explain:
6 If program is outside the CCO/MCO’s service area, did you ask the CCO/MCO for an out-of-area referral?
Yes
No
If no, please explain:
7 How was the client referred to you?
Primary care
Court
Self
Outpatient program
Discharge information
1 Date of discharge
3 If yes, outpatient program name:
2 Referred to outpatient program?
SUD Residential Treatment Program Admission/Discharge Notification
Yes
No
DMAP 7204 (Rev. 10/13)
Substance Use Disorder Residential Program
Admission/Discharge Notification Instruction Sheet
Client information
1 Client Name
2 Client ID
3 Home Address
4 City State ZIP
5 Home County
6 Does this client have accompanying
dependents?
Name of the person receiving treatment at your facility. Enter as
listed on the client’s Oregon DHS Medical ID, Oregon Health ID or
Plan ID.
Enter the 8-digit identifier as listed on the client’s Oregon DHS
Medical ID, Oregon Health ID or Plan ID.
The client’s street address (where they lived prior to entering the
treatment program).If the client is homeless, enter “Homeless.”
The city, state and ZIP code of the client’s home address.
The county of the home address (not of the treatment program).
Check “Yes” or “No.” If the client has dependents residing with
him/her at the treatment facility, also provide the dependents’
names.
Notification information
1 Type of Notification
2 Contact Person Name and Phone
Number
3 Name and Phone Number of person
who completed this form
Check “Adult admission,” “Adolescent admission” or “Discharge.”
This is the person we will contact if we have questions about
information on this form.
If there is missing or invalid information on this form, we will contact
this person first to ask them to resubmit the form.
Program information
1 Licensed Program Name
2 Treatment Program Name and Address
3 Treatment Program City State ZIP
4 Provider Billing ID
5 Program capacity exceeds 16 beds?
This is the name that appears on the actual license issued by AMH.
Enter the actual name of the program, if different from the licensed
name. Also enter the physical address of the treatment facility.
The city, state and ZIP code of the program’s physical address.
Enter your 10-digit National Provider Identifier; or the 6- or 9-digit
provider number issued by DMAP.
Programs that exceed 16 AMH-licensed beds are designated
“Institutes for Mental Disease” (IMD). If you mark “Yes,” we will
ensure that state (not federal) funds reimburse you for services.
Admissions information
1 Date of Admission
2 First Date of Service
3 Projected duration of stay
4 Current physical health enrollment
5 Did you notify the CCO/MCO?
6 Did you ask for an out-of-area referral?
7 How was the client referred to you?
Enter the date the client was admitted to the facility for this report
period.
Enter the first billable date of service.
Tell us how long the treatment plan will be (e.g., 90 days).
Tell us if the client is enrolled with a CCO or MCO, then enter the
CCO/MCO name. If the client is enrolled with neither, select “FFS.”
To coordinate care with the client’s CCO/MCO, you need to let the
CCO/MCO know the client is at your facility. If you have not done
this, please explain why.
If your program is outside the CCO/MCO’s service area, you need to
coordinate with the CCO/MCO to make sure they will cover this
service. If you did not ask for an out-of-area referral, please explain
why.
Self-explanatory
Discharge information
1 Date of discharge
2 Referred to outpatient program?
Enter the last day the client received treatment in your program.
Enter Yes or No.
SUD Residential Treatment Program Admission/Discharge Notification
DMAP 7204 (Rev. 10/13)
3 Outpatient program name
You must enter this information for all discharges.
SUD Residential Treatment Program Admission/Discharge Notification
DMAP 7204 (Rev. 10/13)