OHP Provider Enrollment Forms

NOTE: Effective Sept. 1, 2008, DMAP will only accept provider enrollment forms currently available on this Web site. DMAP will return older versions of these forms for resubmission on the current forms.

The following chart outlines what forms you need to complete and mail in to DMAP Provider Enrollment. Just click on the letter for your provider type, or do a find (Control-F) to find your type in this chart. All enrollment forms are also listed on the DMAP Forms page.

You will need Microsoft Word or Adobe Reader 6.0 or higher to access these documents. Download the latest version of Adobe Reader.

	Forms to Complete
Provider Type	Attachment	Disclosure	Application and Agreement
Acupuncturist	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Air Ambulance	DMAP 3118 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Alcohol and Drug (A&D) acupuncture clinic	DMAP 3119 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
A&D Provider	DMAP 3119 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Ambulance	DMAP 3118 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Ambulatory Surgical Center	DMAP 3117 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Assistive Technology (DME)	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Audiologist	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
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Behavioral Rehabilitation Services	DMAP 3101 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Billing Provider	DMAP 3110 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Billing Service	DMAP 3110 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Birthing Center	DMAP 3117 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Chemical Dependency	DMAP 3119 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Chiropractor	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Clinic (bills for practitioners in the clinic/group) Medical clinic Nurse practitioner clinic Dental clinic Therapy clinic Pediatric clinic Speech/hearing clinic	DMAP 3110 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Community Health Support Program (SPD) RN Provider	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Cost-Based Clinic	None	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Copy Center	None	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Cost-Based Clinic	None	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
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Dental Hygienist Dental Hygienist with Limited Access Permit   If the dentist or dental clinic bills for your services:	DMAP 3102H (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
	Do not complete any forms. DMAP will pay the dentist/clinic for your services.
Dental Prosthesis	DMAP 3102D (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Dentist	DMAP 3102D (Word) (PDF)	DHS 3973 ((Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Denturist	DMAP 3102D (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Detoxification	DMAP 3119 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Dietician	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Dietician (Maternity Case Management)	DMAP 3114M (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Dispensing Optician	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
DME provider with Assistive Technology Practitioner (ATP), Assistive Technology Supplier (ATS) or Rehabilitation Engineering Technologist (RET)	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
DUII alcohol/other drug information program	DMAP 3119 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
DUII alcohol/other drug rehabilitation program	DMAP 3119 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Durable Medical Equipment Dealer	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Education Service District	DMAP 3120 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Emergency Medical Response	DMAP 3116 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Endodontist	DMAP 3102D (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Enteral/Parenteral Nutrition	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Enteral/Parenteral Services	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
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Family Planning Clinic	DMAP 3117 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Federally Qualified Health Center	DMAP 3104 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Free-Standing Kidney Dialysis Center   If a group bills for your services:	DMAP 3109 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
	Also complete the DMAP 3110 (Word) (PDF)
Ground Ambulance	DMAP 3118 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Groups or Practices	DMAP 3110 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
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Hearing Aid Dealer	DMAP 3116 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Home Enteral/Parenteral and IV Services	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Home Health Agency	DMAP 3117 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Hospice	DMAP 3117 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Hospital	DMAP 3111 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Hospital-Based Clinic	DMAP 3111 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Hospital Psychiatric Unit	DMAP 3111 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Independent Labs   If a group bills for your services:   If a hospital bills for your services:	DMAP 3112 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
	Also complete the DMAP 3110 (Word) (PDF)
	Do not complete any forms. DMAP will pay the hospital for your services.
Indian Health Services Clinic	DMAP 3104 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Licensed Clinical Social Worker (Maternity Case Management)	DMAP 3114M (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Licensed Clinical Social Worker	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Licensed Practical Nurse	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Long-term care facility	DMAP 3117 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
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Medical Doctors - Osteopaths	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Medical Doctors - Physicians	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Medical Supply Company	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Medical Supply Company with Orthotics Personnel	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Medical Supply Company with Pedorthic Personnel	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Medical Supply Company with Prosthetics Personnel	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Medical Supply Company with Registered Pharmacist	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Medical Supply Company with Respiratory Therapist	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Mental Health Clinic	DMAP 3117 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Midwife - Licensed Direct Entry Midwife	DMAP 3114M (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Mobile Labs   If a group bills for your services:   If a hospital bills for your services:	DMAP 3112 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
	Also complete the DMAP 3110 (Word) (PDF)
	Do not complete any forms. DMAP will pay the hospital for your services.
Naturopath	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Neonatal Intensive Transportation	DMAP 3118 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Nurse Anesthetist	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Nurse Practitioner	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Nutritionist (Maternity Case Management)	DMAP 3114M (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
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Occupational Therapist	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Optician	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Optometrist	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Oral Pathologist	DMAP 3102D (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Oral Surgeon (Dental)	DMAP 3102D (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Oral Surgeon (Medical)	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Orthodontist	DMAP 3102D (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Orthotics Personnel	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Orthotics/Prosthetics Personnel	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Osteopaths	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Outpatient synthetic opiate treatment program	DMAP 3119 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Oxygen Supplier	DMAP 3116 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
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Pedorthic Personnel	DMAP 3116 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Periodontist	DMAP 3102D (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Pharmacy - DMEPOS Supplier	DMAP 3116 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Pharmacy - Retail and Institutional Indian Health Services Pharmacy 340B Pharmacy Nursing Facility Pharmacy Specialty Pharmacy Rural Health Clinic Pharmacy	DMAP 3115 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Physical Therapist	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Physicians	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Physician Assistants	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Podiatrist	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Polygrapher	DMAP 3107 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Portable X-Ray   If a group bills for your services:   If a hospital bills for your services:	DMAP 3105 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
	Also complete the DMAP 3110 (Word) (PDF)
	Do not complete any forms. DMAP will pay the hospital for your services.
Prenatal Clinic	DMAP 3117 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Prosthetics Personnel	DMAP 3116 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Psychologist	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Public Health Clinic	DMAP 3117 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Public School District	DMAP 3120 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Registered Nurse (RN)	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Residential Treatment Facility - Chemical Dependency Services	DMAP 3119 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Residential Treatment Facility - Mental Health Services	DMAP 3117 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Respiratory Therapist	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
RN First Assistant	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Rural Health Clinic	DMAP 3104 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Rural Health Clinics with practitioners licensed to dispense medicine	DMAP 3115R (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
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School Medical	DMAP 3120 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Servicar	DMAP 3118 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Sex Offender Polygrapher	DMAP 3107 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Special Inpatient Care Facility	DMAP 3117 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Speech and Hearing Therapist	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Speech/Language Pathologist	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Stretcher Car	DMAP 3118 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Substance abuse treatment program - Inpatient or Outpatient	DMAP 3119 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
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Targeted Case Management Babies First/Cocoon HIV Case Management Early Intervention/Early Childhood Special Education Federally Recognized Tribal Governments	DMAP 3103 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Taxi	DMAP 3118 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Tobacco Cessation	DMAP 3114 (Word) (PDF)	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Translator	None	DHS 3973 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Transportation Broker	DMAP 3118 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Tribal 638 Clinic	DMAP 3104 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Urban Clinic	DMAP 3114 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
Wheelchair Coach/Van/Servicar	DMAP 3118 (Word) (PDF)	DHS 3974 (Word) (PDF)	DHS 3972 (Word) (PDF) DHS 3975 (Word) (PDF)
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