Individual practitioners

Entities, agencies, facilities, organizations

Behavioral Rehabilitation Services: DMAP 3101 (Word) (PDF)

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Billing Providers: DMAP 3110 (Word) (PDF). To participate as a Patient-Centered Primary Care Home (PCPCH) provider, also complete the DMAP 3129 (PCPCH Provider Attachment).

• Billing Service
• Clinic (bills for practitioners in the clinic/group)
• Groups or Practices

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Chemical Dependency Providers: DMAP 3119 (Word) (PDF)

• A&D Provider
• Alcohol and Drug (A&D) acupuncture clinic
• Chemical Dependency
• Detoxification
• DUII alcohol/other drug information program
• Outpatient synthetic opiate treatment program
• Residential Treatment Facility - Chemical Dependency Services
• Substance abuse treatment program - Inpatient or Outpatient

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Dental Hygienists: DMAP 3102H (Word) (PDF)

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Dental Providers: DMAP 3102D (Word) (PDF)

• Dental Prosthesis
• Dentist
• Denturist
• Endodontist
• Oral Pathologist
• Oral Surgeon (Dental)
• Orthodontist
• Periodontist

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Durable Medical Equipment and Prosthetics, Orthotics and Supplies Providers: DMAP 3116 (Word) (PDF)

• Assistive Technology Practitioner (ATP)
• DME provider with ATP, Assistive Technology Supplier (ATS) or Rehabilitation Engineering Technologist (RET)
• Durable Medical Equipment Dealer
• Enteral/Parenteral Nutrition
• Hearing Aid Dealer
• Medical Supply Company (with Orthotics, Pedorthic or Prosthetics Personnel; Registered Pharmacist; or Respiratory Therapist)
• Orthotics/Prosthetics Personnel
• Oxygen Supplier
• Pedorthic Personnel

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Facility Providers: DMAP 3117 (Word) (PDF)

• Ambulatory Surgical Center
• Birthing Center
• Family Planning Clinic
• Home Health Agency
• Hospice
• Long-term care facility
• Mental Health Clinic
• Prenatal Clinic
• Public Health Clinic
• Residential Treatment Facility - Mental Health Services
• Special Inpatient Care Facility

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Health Centers: DMAP 3104 (Word) (PDF). To participate as a Patient-Centered Primary Care Home (PCPCH) provider, also complete the DMAP 3129 (PCPCH Provider Attachment). Also complete the DMAP 3108 (PDF) for each individual practitioner at your facility.

• Federally Qualified Health Center
• Indian Health Services Clinic
• Rural Health Clinic
• Tribal 638 Clinic

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Hospital Providers: DMAP 3111 (Word) (PDF)

• Hospitals
• Hospital Psychiatric Unit
• Hospital-Based Clinic

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Independent Laboratory Providers: DMAP 3112 (Word) (PDF).If a clinic or group bills on your behalf, also complete the DMAP 3110 (Word) (PDF).

• Mobile Labs

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Independent Radiology Providers: DMAP 3105 (Word) (PDF). If a clinic or group bills on your behalf, also complete the DMAP 3110 (Word) (PDF).

• Portable X-Ray

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Maternity Case Management Professionals: DMAP 3114M (Word) (PDF)

• Dietician
• Licensed Clinical Social Worker
• Midwife - Licensed Direct Entry Midwife
• Nutritionist

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Medical Professionals: DMAP 3114 (Word) (PDF)

• Acupuncturist
• Audiologist
• Chiropractor
• Community Health Support Program (SPD) RN Provider
• Dietician
• Dispensing Optician
• Enteral/Parenteral Services
• Home Enteral/Parenteral and IV Services
• Licensed Clinical Social Worker
• Licensed Marriage Family Therapist
• Licensed Practical Nurse
• Licensed Professional Counselors
• Medical Doctors – Osteopaths and Physicians
• Naturopath
• Nurse Anesthetist
• Nurse Practitioner
• Occupational Therapist
• Optician
• Optometrist
• Oral Surgeon (Medical)
• Pharmacist (for Medication Therapy Management services)
• Physical Therapist
• Physician Assistants
• Podiatrist
• Psychologist
• Registered Nurse (RN)
• Respiratory Therapist
• RN First Assistant
• Speech and Hearing Therapist
• Speech/Language Pathologist
• Tobacco Cessation

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Pharmacy - Retail and Institutional: DMAP 3115 (Word) (PDF)

• 340B Pharmacy
• Indian Health Services Pharmacy
• Nursing Facility Pharmacy
• Rural Health Clinic Pharmacy
• Specialty Pharmacy

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Renal Dialysis Providers: DMAP 3109 (Word) (PDF)

• Free-Standing Kidney Dialysis Center

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Rural Health Clinics with practitioners licensed to dispense medicine: DMAP 3115R (Word) (PDF)

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School Medical Providers: DMAP 3120 (Word) (PDF)

• Education Service District
• Public School District
• School Medical

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Sex Offender Polygrapher Examiner Specialist: DMAP 3107 (Word) (PDF)

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Targeted Case Management: DMAP 3103 (Word) (PDF)

• Babies First/Cocoon
• HIV Case Management
• Early Intervention/Early Childhood Special Education
• Federally Recognized Tribal Governments

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Transportation Providers: DMAP 3118 (Word) (PDF)

• Air Ambulance
• Ambulance
• Ground Ambulance
• Neonatal Intensive Transportation
• Servicar
• Stretcher Car
• Taxi
• Transportation Broker
• Wheelchair Coach/Van/Servicar

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