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How to become an Oregon Health Plan provider

All health care providers must provide DMAP their 10-digit National Provider Identifier (NPI) when enrolling as an Oregon Medicaid provider. (Providers not subject to NPI, such as transportation providers, are not required to provide an NPI.)

  • To get an NPI, apply online at the National Plan and Provider Enumeration System (NPPES) website.
  • To look up your NPI information, use the NPI Registry.

    If you want to enroll with DMAP:

    Try our online enrollment process. It provides links to additional forms you need to complete and submit.

    Or, use the drop down box below to select the type of “Provider description” that matches you or the services you provide.

    • Complete and fax all forms and documentation listed for your description to DMAP under an EDMS Coversheet (MSC 3970). Starting March 1, 2014, we will no longer process requests submitted without the EDMS Coversheet.
    • If you are an out of state provider (more than 75 miles outside the Oregon border) seeking payment for services to OHP members, also include the claim you are seeking payment for.
    • If you do not bill us, but need to be reported in our system for other reasons (such as obtaining Provider Web Portal or Automated Voice Response access, or rendering/ ordering/ prescribing/ referring services for OHP members), select "Non-Payable Provider" from the drop down box below.
     
    Provider Description
      
    Required Forms
    Required Documents
      
    Acupuncturist
    02

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Alcohol and Drug Counselors (CADC)
    03

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    AMH certification, CADC certificate information, SSN documentation
    Alcohol and Drug - Chemical Dependency Facility
    03

    DMAP 3119 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of AMH certification, IRS letter
    Ambulatory Surgical Center
    05

    DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter
    AMH Adult Foster Home (Individual)
    33

    OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    AMH Adult Foster Home (I-Plan)
    33

    OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, Fitness form, SSN documentation
    AMH Adult Foster Home (Residential)
    33

    DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter
    AMH Personal Care 20 Attendant
    30

    OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, Fitness form, I-9 form, SSN documentation
    Audiologist
    45

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Behavior Rehabilitation Services
    (counties that provide local match funding)
    06

    DMAP 3101 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter
    Billing Provider (clinic/group billing)
    09

    DMAP 3110 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter
    Birthing Center
    08

    DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter
    Chiropractor
    16

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Copy Services
    12

    OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter
    Dental Hygienist
    18

    DMAP 3102H (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Dentist
    17

    DMAP 3102D (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Denturist
    20

    DMAP 3102D (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Direct Entry Midwife
    41

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Dispensing Optician (Individual)
    44

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Durable Medical Equipment (DME)
    36

    DMAP 3116 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter, Medicare information, Surety bond (unless exempted)
    Emergency Response (Lifeline)
    92

    OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter
    Family Planning Clinic
    22

    DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter, Pharmacy license (if applicable)
    Federally Qualified Health Center (FQHC)
    15

    DMAP 3104 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    HRSA grant designation, IRS letter, Medicare cost report
    Hearing Aid Dealer
    23

    OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Home Health Agency
    24

    DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter, Medicare information
    Hospice
    27

    DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter, Medicare information
    Hospital
    26

    DMAP 3111 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter, Medicare information
    Independent Diagnostic Testing Facility
    09

    DMAP 3110 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter, Medicare information
    Independent Laboratory
    29

    DMAP 3112 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    CLIA certification, IRS letter
    Kidney Dialysis Center (Renal Disease Clinic)
    32

    DMAP 3109 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter
    Licensed Clinical Social Worker
    69

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Mental Health LFMT
    33

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Mental Health LPC
    33

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Mental Health PMHNP
    33

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Mental Health Psychiatrist
    33

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Mental Health Psychologist
    33

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Mental Health QMHP and QMHA
    33

    ​​DMAP 3113 (Word) (PDF)

    Mental Health Services - Outpatient/Inpatient Care Facility
    33

    DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    AMH certification, IRS letter
    Mental Health Services - Residential Treatment Facility
    33

    DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    AMH certification, IRS letter
    Mobile Labs
    09

    DMAP 3110 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter
    Naturopath
    38

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Nurse Practitioner (Advance Practice Nurse)
    42

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Nursing Care Facility
    81

    DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter, Medicare information
    Occupational Therapist
    45

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Optical Clinic
    44

    DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter
    Optometrist
    43

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Oral Surgeon (Dental)
    17

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Oral Surgeon (Medical)
    34

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Oregon State Hospital
    35

    DMAP 3111 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter, Medicare information
    Pharmacist
    50

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Pharmacy
    48

    DMAP 3115 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter
    Physical Therapist
    45

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Physician Assistant
    46

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Physicians
    34

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Podiatrist
    19

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Polygrapher
    54

    DMAP 3107 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Portable X-ray
    52

    DMAP 3105 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter, Machine registration license, Medicare information
    Psychologist
    53

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Public Health Clinic
    47

    DMAP 3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter, Pharmacy license (if applicable)
    Registered Dietician
    58

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Registered Nurse Anesthetist
    37

    OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    RN First Assistant
    57

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Rural Health Clinic (RHC)
    14

    DMAP 3104 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter, Medicare information
    School Medical
    62

    DMAP 3120 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter
    Speech and Hearing Therapist
    45

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Speech and Language Pathologist
    45

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, SSN documentation
    Targeted Case Management
    64

    DMAP 3103 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter
    Transportation Air Ambulance
    01

    DMAP 3118 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter
    Transportation Broker
    01

    DMAP 3118 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter
    Transportation Ground Ambulance
    01

    DMAP 3118 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, IRS letter
    Tribal Health Center (Indian Health Service or Tribal 638)
    18

    DMAP 3104 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    IRS letter
    LTC Nursing Agency
    88

    DMAP ​3117 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, DHS/APD authorization and contract number, IRS letter
    LTC Nursing Services (formerly Contract RN)
    86

    DMAP 3114 (Word) (PDF), OHA 3972 (Word) (PDF), OHA 3973 (Word) (PDF), OHA 3975 (Word) (PDF)

    Copy of license, DHS/APD authorization and contract number, SSN documentation
    Behavior Rehabilitation Services
    (organizations that do not provide local match funding)
    06

    DMAP 3110 (Word) (PDF​), OHA 3972 (Word) (PDF), OHA 3974 (Word) (PDF), OHA 3975 (Word) (PDF)​

    IRS letter
    Non-Payable Provider
    --

    ​DMAP 3113 (Word) (PDF)

     

    If you want to enroll with an OHP health plan:

    Medical and behavioral health providers: If you have questions about enrolling with a Coordinated Care Organization (CCO), contact the CCO. If you were denied participation in an OHP medical plan's provider network, read about the OHA Provider Discrimination Review process and form (Word) (PDF).

    Dental providers: If you have questions about enrolling with an OHP dental plan, contact the plan.

    Need help?

    • To check enrollment status: Try our online enrollment tracking.
    • To get help enrolling with DMAP: Call DMAP Provider Enrollment at 1-800-422-5047 or e-mail provider.enrollment@state.or.us.
    • To stay enrolled: Submit updates within 30 days of the change on either the Provider Web Portal Demographic Maintenance panel or DMAP 3035 form (Word) (PDF). Also send us a copy of your licensure renewal when you receive it from your licensing board.
    • To request direct deposit: Submit the MSC 189 (Direct Deposit Authorization Form) to DHS/OHA Financial Services. For Medicaid EHR Incentive Program payments, enter the Oregon Medicaid provider number and account information associated with the payee you identified when registering with CMS for EHR incentive payments.