Get Or Dmap 3119 2014-2025

Filling out the OR DMAP 3119 form is an essential step for Substance Use Disorder Programs aiming to enroll with Oregon Medicaid. This guide will provide you with clear and detailed instructions to help ensure your form is completed accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the OR DMAP 3119 and open it in the editor.
2. Begin by entering the date in the designated field at the top of the form.
3. Select the appropriate Oregon Medicaid provider type from the list provided. Ensure you choose the type that accurately describes your program.
4. Enter your current business or facility license number in the specified field and attach a copy of all necessary licenses and certificates that authorize your program's operation.
5. Input your laboratory's CLIA number and attach a copy of the current CLIA Certification letter.
6. If applicable, provide the name of your contracting laboratory and its CLIA number, along with any certification letters.
7. List any provider numbers assigned to you by Oregon Medicaid previously or currently if applicable.
8. Indicate if the program is owned or operated by a government unit and check all relevant boxes.
9. If applicable, enter your rates in the designated area and attach a copy of your fee schedule.
10. Provide information about your general and professional liability insurance, listing the carrier name, policy number, expiration date, and amount insured per occurrence.
11. Indicate whether licensed staff exclusively are employed; if yes, attach a staff list with their credentials.
12. If hiring any unlicensed staff, acknowledge your commitment to seeking AMH certification.
13. Confirm whether your hiring practices comply with AMH certification requirements if employing unlicensed staff.
14. Check all entities you contract with from the provided options.
15. For out-of-state programs, enter the name and contact number of the Medicaid office in your state that can confirm your enrollment.
16. Review all completed sections for accuracy and completeness. Once satisfied, save your changes and choose to download, print, or share the completed form.

Start completing the OR DMAP 3119 online to ensure your program is properly enrolled with Oregon Medicaid.