Skip to main content

Oregon State Flag An official website of the State of Oregon » Homepage

DCO Contract Forms


The dental care organization (DCO) contracts with the Oregon Health Authority (OHA) require DCOs to submit various reports. Templates, related forms and documents for these reports are listed here.

Fraud, Waste and Abuse (FWA) policies and procedures:

Exhibit B, Part 9, subsection 17 (Obligations to Report FWA: Policies and Procedures) b. and  c. of the DCO contracts require use of a reporting template. DCOs will be using the CCO template for their submissions.

Also refer to the CMS Medicaid Program Integrity website for more information about how to implement FWA policies and procedures at the practice level.

Financial Reports

Other Reports

DCO-Attestation-Form-Approved-Documents-CY2022.docxAttestation Form for Previously Approved Documents, CY 2022 05-2022
DCO-Claim-Count-Verification-Acknowledgment-Action-Form.docClaim Count Verification Acknowledgment and Action Form, 10-1-2014
DCO-Data-Certification-Validation-Report-Form.docData Certification and Validation Report Form, 10-1-2014
DCO-Member-Transition-Closeout-Plan-063022.docxDCO Member Transition and Close-Out Plan, 6-2022
Delegation-Authorization-Signature-Form-2021.pdfDelegation Authorization and Signature Form, 05-2021 (PDF)
Delegation-Authorization-Signature-Form-2021.docDelegation Authorization and Signature Form, 05-2021 (Word)
DCO-DSN-Provider-Narrative-Report-Instructions-2021.pdfDSN Annual Provider Narrative Instructions, 05-2021
DCO-DSN-Provider-Narrative-Template-2021.xlsxDSN Annual Provider Narrative Template, 05-2021
Discrepancies-Found-Report.xlsxEnrollment Reconciliation - Discrepancies Found Report, 05-2021
Discrepancies-Found-Form.docxEnrollment Reconciliation Certification - Discrepancies Found, 05-2021
No-Discrepancies-Found-Form.docxEnrollment Reconciliation Certification - No Discrepancies Found, 05-2021
FWA-Audit-Report-2023.xlsxFWA Audit Report Template for CY 2023, 01-2023
DCO-FWA-Deliverables-Review-CY2021.docxFWA Deliverables Review Template CY 2021
DCO-FWA-Deliverables-Review-CY2022.docxFWA Deliverables Review Template CY 2022
Program-Integrity-Glossary-0122.pdfFWA Program Integrity Glossary of Terms, 01-2022
DCO-Grievance-System-Report.docxGrievance System Report
DCO-Grievance-System-Reporting-Instructions.docxGrievance System Reporting Instructions
DCO-Health-Equity-Assessment-Template-2022.docxHealth Equity Assessment Template, 07-2022
DCO-Language-Access-Quarterly-Report-Instructions.xlsxLanguage Access Quarterly Report Instructions 03-2020
Language Access Taglines_OHP Medicaid CCO Letters_15 languages.docxLanguage Access Taglines_OHP Medicaid CCO Letters_15 languages
DCO-Language-Self-Assessment-Template120921.pdfLanguage Self-Assessment Template, 12-2021
Model-Depository-Agreement-for-DCOs.docxModel Depository Agreement for DCOs
DCO-TPLR-PP-Evaluation-Criteria-2022.pdfThird-Party Liability Recovery P&P Evaluation Criteria, 04-2022


This page is only for DCOs whose direct contracts with OHA ended December 31, 2022. DCOs should only use the documents on this page if required for their contract close-out activities with OHA.

DCOs subcontracted by coordinated care organizations (CCOs) must contact their CCO for information about deliverables documents that may apply to their subcontract.

Contract Template