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Get OR DMAP 3119 2014-2024

) (Date) In order to enroll as a Substance Use Disorder Program with Oregon Medicaid, you must complete this attachment and return it with the following information: Completed OHA 3972 (Provider Enrollment Request) Signed and dated OHA 3974 (Disclosure Statement of Ownership and Control Interest) Signed and dated OHA 3975 (Provider Enrollment Agreement) Copy of current license(s), certificates and other information requested below 1. Oregon Medicaid provider type (select one): This attachment.

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