HomeMy WebLinkAboutDoc 094 - IGA - Oregon Health AuthorityDeschutes County Board of Commissioners
1300 NW Wall St., Suite 200, Bend, OR 97701-1960
(541) 388-6570 -Fax (541) 385-3202 -www.deschutes.org
AGENDA REQUEST & STAFF REPORT
For Board Business Meeting of March 18, 2013
DATE: March 14,2013
FROM: Nancy Mooney, Contract Specialist, Deschutes County Health Services, 322-7516
TITLE OF AGENDA ITEM:
Consideration of Chair Signature of Document #2013-094, Intergovernmental Agreement between the
Oregon Health Authority (OHA) and Deschutes County Health Services, Public Health Division.
PUBLIC HEARING ON THIS DATE? No.
BACKGROUND AND POLICY IMPLICATIONS:
OHA is at the forefront of lowering and containing costs, improving quality and increasing access to
health care in order to improve the lifelong health of Oregonians. In the public sector, OHA will
consolidate most of the state's health care programs, including Public Health, the Oregon Health
Plan (OHP), HealthyKids Connect, employee benefits and public-private partnerships. This will give
the state greater purchasing and market power to begin tackling issues with costs, quality, lack of
preventive care and health care access. In both the public and the private sector, OHA will be
working to fundamentally improve how health care is delivered and paid for, but because poor
health is only partially due to lack of medical care, OHA will also be working to reduce health
disparities and to broaden the state's public health focus. Ultimately, OHA is charged with
delivering a plan to the Legislature to ensure that all Oregonians have access to affordable health
care.
This agreement sets forth the conditions for Deschutes County as a provider agency with OHA for
reimbursement regarding contraceptive management services, supplies or devices furnished by
Deschutes County to persons eligible for OregonContraceptiveCare (CCare) in Oregon. Through
the CCare program, Deschutes County provides birth control/contraceptive services to residents
who are not enrolled on the Oregon Health Plan.
FISCAL IMPLICATIONS:
Maximum funding is budgeted to be $550,000.
RECOMMENDATION & ACTION REQUESTED:
Request approval and signature from Board of County Commissioners, Chair Signature, for Document
#2013-094, Intergovernmental Agreement between the Oregon Health Authority and Deschutes
County Health Services, Public Health Division.
ATTENDANCE: Kathy Christensen, Clinical Program Supervisor
DISTRIBUTION OF DOCUMENTS:
Executed documents to Nancy Mooney, Contract Specialist
DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: This form is required to be submitted with ALL contracts and other agreements, regardless of whether the document is to be
on a Board agenda or can be signed by the County Administrator or Department Director. If the document is to be on a Board
agenda, the Agenda Request Form is also required. If this form is not included with the document, the document will be returned to
the Department. Please submit documents to the Board Secretary for tracking purposes, and not directly to Legal Counsel, the
County Administrator or the Commissioners. In addition to submitting this form with your documents, please submit this form
electronically to the Board Secretary.)
Please complete all sections above the Official Review line.
Date: 1 February 27,2013 1
Department: 1 Health Services, Public Health Division .1
Contractor/Supplier/Consultant Name: 1 Oregon Health Authority
Contractor Contact: Pi Winslow 11
Contractor Phone #: 1971-673-02271
Type of Document: Personal Services Agreement
Goods and/or Services: The Oregon Health Authority (OHA) was created by the 2009 Oregon
legislature to bring most health-related programs in the state into a single agency to maximize its
purchasing power.
Background & History: OHA is at the forefront of lowering and containing costs, improving
quality and increasing access to health care in order to improve the lifelong health of
Oregonians. In the public sector, OHA will consolidate most of the state's health care programs,
including Public Health, the Oregon Health Plan (OHP), HealthyKids Connect, employee
benefits and public-private partnerships. This will give the state greater purchasing and market
power to begin tackling issues with costs, quality, lack of preventive care and health care
access. In both the public and the private sector, OHA will be working to fundamentally improve
how health care is delivered and paid for, but because poor health is only partially due to lack of
medical care, OHA will also be working to reduce health disparities and to broaden the state's
public health focus. Ultimately, OHA is charged with delivering a plan to the Legislature to
ensure that all Oregonians have access to affordable health care.
This agreement sets forth the conditions for Deschutes County as a provider agency with OHA
for reimbursement regarding contraceptive management services, supplies or devices furnished
by Deschutes County to persons eligible for OregonContraceptiveCare (CCare) in Oregon.
Through the CCare program, Deschutes County provides birth control/contraceptive services to
residents who are not enrolled on the Oregon Health Plan.
Agreement Start Date: I March 1, 2013 (estimated) lEnd Date: I March 31, 20181
Annual Value or Total Payment: 1 Maximum compensation is budgeted to bel
$550,000 per year. I
2/28/2013
Check all that apply:
D RFP, Solicitation or Bid Process
D Informal quotes «$150K)
r8J Exempt from RFP, Solicitation or Bid Process (specify -see DCC §2.37)
Funding Source: (Included in current budget? r8J Yes D No
If No, has budget amendment been submitted? DYes D No
Is this a Grant Agreement providing revenue to the County? DYes r8J No
Special conditions attached to this grant:
Deadlines for reporting to the grantor: 1...-1_--J
If a new FTE will be hired with grant funds, confirm that Personnel has been noti'fied that
it is a grant-funded position so that this will be noted in the offer letter: DYes D No
Contact information for the person responsible for grant compliance: Name:
Phone #: '-----'
Departmental Contact and Title: I Nancy Mooney, Contract Specialist
Phone #: I 541-322-7516 I
Department Director Approval: ---.....::..-t:--'\!...l."L..-----~ t l3
Date
Distribution of Document: executed documents to Nancy Mooney, Contract
Specialist
Official Review: Ik2tt/i 11k..e~/.:;~.,JJ ~h~ol¥ (l::e bOJ. ~~IU(/' a f2, 1f'1e" -(l~(N J-<J:ii~ rlY" t!ti~iII~ s.(j~';"<r-{
County Signature Required (check one): !R BOCC 0 Department Director (if <$25K)
Administrator (if >$25K but <$150K; if >$150K, BOCC Order No. ____-I)
Legal Review Date I-f;-I)1~ CJ
Document Number =20:..1.:..::3<--0:..::9<-4"---______
2/28/2013
7?k~IEf;J
I EGA! COllNSEIPUBLIC HEALTH DIVISION
Center for Prevention and Health Promotion
Reproductive Health Program
800 NE Oregon Street, Suite 370
Portland, OR 97232 egalth
-----;-\uthority
oregon contraceptive co re
MEDICAL SERVICES AGREEMENT
This Medical Services Agreement sets forth the conditions for being enrolled as a provider agency
(Agency) with the State of Oregon, Oregon Health Author~y (OHA), Center for Prevention and
Health Promotion (CPHP) and to receive payment by CPHP for contraceptive management
services, supplies or devices (CCare services) furnished by Agency to persons eligible (Clients) for
OregonContraceptiveCare (CCare) in Oregon.
Eligibility in the CCare Program is conditioned on the Agency's execution and delivery of the
application and required certification . The information disclosed by the Agency may be subject to
verification by CPHP. This information will be used for purposes related to the administration of the
CCare Program.
As a condition for participation as an Agency with OHA, Agency agrees as follows:
A. Services:
1. To provide CCare services to individuals covered by the Oregon Health Plan (OHP) as
well as Clients.
2. Be an enrolled OHP Provider prior to final approval as a CCare Agency and comply
with all applicable Division of Medical Assistance (DMAP) statutes and rules.
3. Adhere to all applicable OARs. "OARs" means the CPHP Oregon Administrative
Rules, OAR 333-004-0000 through 333-004-0230, as those rules may be adopted or
amended from time to time.
4. Comply with the Reproductive Health Program Manual that can be found on the
Reproductive Health Program Provider Resources web site at
www.healthoregon.org/rhmaterials.TheReproductiveHealthProgrammanual.as
amended from time to time, is hereby incorporated by reference.
5. To perform all CCare services for which CPHP pays the Agency under this Medical
Services Agreement (Agreement) as an independent contractor. The Agency is not an
"officer", "employee", or "agent" of CPHP or OHA, as those terms are used in ORS
30.265.
B. Accurate billing: To certify by Signature of the Agency or designee, induding electronic
Signatures on a claim form or transmittal document, that the care, service, equipment or
supplies claimed were actually provided and medically appropriate, were documented at the
time they were provided, and were provided in accordance with profeSSionally recognized
standards of health care, OARs and this Agreement. The Agency is solely responsible for
the accuracy of claims submitted and the use of a billing entity does not change the
CCare Medical Services Agreement OHA 1013 (11/12)
Page 1 of 4
DC-2013-09
H. Eligibility and continued participation; provider sanctions and payment recovery:
Failure to comply with the terms of this Agreement or the OARs, failure of the application or
certificate to be accurate in any respect, or failure to notify CPHP of changes in name,
address, business affiliation, licensure, or ownership may result in sanctions, termination of
the agreement, or payment recovery pursuantto OAR 333-004-0140 through 333-004-0160,
subject to Provider appeal rights described in OAR 333-004-0200 through 333-004-0230.
I. Effective date: This Agreement is effective upon the date of approval of the CPHP
representative, as indicated by the signature at the end of the Agreement or upon the date
of approval as an OHP provider by DMAP, whichever is the later. Any prior contract, price
agreement or vendor agreement between OHA and Agency for CCare services is
terminated immediately upon execution of this Agreement.
AGENCY
By signing this Agreement you acknowledge that you have read the Agreement, understand the
terms of the Agreement and agree to be bound by the terms and conditions of the Agreement.
Signature of agency authorized business representative Date
Alan Unger, Chair
Deschutes County Board of CommissionersPrinted name
Title of business representative
CPHP: By its signature, the Center for Prevention and Health Promotion certifies that the
Agency qualifies as a CCare Program Provider Agency.
By: ____________________________________ Date: _______________
Bruce Gutelius
Printed name
Center for Prevention and Health Promotion Administrator
Title
\
I
i
I
t
CCare Medical Services Agreement OHA 1013 (11112)
Page 3 of4
The Oregon Reproductive Health Program Manual and the Oregon Administrative
Rules can be downloaded from www.healthoregon.org/rhmaterials.
NOTE: If a provider changes name, address, business affiliation, licensure, ownership
or certification, CPHP and DMAP must be notified in writing within 30 days of the
change. Payments made to providers who have notfurnished such notification may be
recovered.
Applications must be signed and dated by the Provider Agency Representative.
CPHP will not accept stamped signatures. CPHP will return incomplete
applications.
All written correspondence regarding this Medical Services Agreement, including
application and termination notice, should be sent to:
CCare Provider Enrollment
800 NE Oregon Street, Suite 370
Portland, Oregon 97232
CCare Medical Services Agreement OHA 1013 (11/12)
Page 4 of4
{?J:;~ PUBLIC HEALTH DIVISION '.. ,,9 Reproductive Health Program ealth-----\11.1 i;\"§i~~;7 John A, Kitzhaber, M.D., Governor
800 NE Oregon Street Suite 370
Portland, OR 97232
Voice 971-673-0355
FAX 971-673-0371February 22, 2013 http://WWN,healthoregon.gov/rh
TO: CCare Program Administrators
FROM: OHA Reproductive Health Program
RE: Revised Medical Services Agreement for CCare Providers
The Reproductive Health Program has updated its OregonContraceptiveCare (CCare)
provider agreements to reflect the name change of Oregon's Section 111S(a) waiver from
FPEP to CCare and also to include new language used in our recently revised OARs. In
partnership with the Department of Medicaid Assistance Programs (DMAP) who has also
updated their provider agreements, we are requiring all current CCare providers to
complete the attached forms and return them to our office by March 15th 2013.
These documents are a requirement to continue to be a contracted CCare provider and to
receive payment reimbursement for CCare services. This agreement will remain in effect
for the next five years, at which time it will need to be renewed again.
You may email, fax or mail the signed agreements to our office.
If you have any questions, please contact:
Pi Winslow 971-673-0227, pi.v.winslow@state.or.us
Stal. 01 QleSon
~~t;!~~uA:~~:::'~:ogram.
DHS PROVIDER ApPLICATION -FAMIL"
.. ~,!,~ ..J/:iQMftM, .~l~ (Read Instructions before
1 Busiile$S Name
2 Ph~'sical LocaUon
('Ie U:Jvrl-1"~r.:riVf:....
~o\ .. --.---.. ----,=~._-----._:_;cr_-=_--"T
4 Area Code· Phone #'=-.LL--"''-==--_II<C.--'-___
located)
140
540
150
550
200
560
330
900
340
Medical Provider Enrollment Agreement
111is Enrollment Agreement sets forth the relationship between the State of Oregon, Department of Human Services
("Department"), Office of Family Health ("OFH") and Office of Medical Assistance Programs ("OMAP") and
~~cby,k:,s l(,YI'\~lJe"lH; ~rovidel''') regarding payment by OFH or OMAP for Contraceptive Management
Services, supplies or devices, as defined in OAR 333-004-0010, furnished by Provider to persons eligible ("Recipients")
for medicall\ssistance through OMAP or the Family Planning Expansion Program in Oregon. If Provider is a Federally
Qualified Health Center (FQHC), Rural Health Clinic (RHC), Indian Health Services (HIS), or Tribal facility, then OMAP is
not a party to this agreement, and references to OMAP's rights or obligations shall have no effect.
A. fu:ryJru When providing conti"aceptive management services, supplies or devices to Recipients for which payment
is requested from OPH or OMAp, the Provider shall adhere to all applicable OFH or OMAP rules. "OFH Rules" means
the OPH Administrative Rules, 333-004-000 through 333-004-0190, and FPEP program manuaL as amended from time to
time. "OMAP Rules" means OMAP General Rules (Chapter 410 Division 120), Oregon Health Plan Rules (Chapter 410
Division 141) and Medical-Surgical Services Rule 410-130-0587, all as amended from time to time.
AU services for which OFH or OMAP pays Provider under this Enrollment Agreement are services performed solely as an
independent contractor. Provider is not an "officer", "employee", or "agent" of OFH, OMAP or Department, as those terms
are used in ORS 30.265.
B. Payment Subject to the-requirements of the OFH and OMAP Administrative Rules, and the terms and conditions of
this Enrollment Agreementt OFH and OMAP agree to make payment to Provider for covered Contraceptive Management
Services, supplies or devices received h}' Recipients. Payment for services provided to Recipients not enrolled in the
Oregon Health Plan (OHP) is the sole responsibility of OFH. Payment for services to Recipients enrolted in the OHP is
the sole responsibility of OMAP. Eligibility for payment is determined using the procedures described in OFH or OMAP
Administrative Rules. Except as provided in the OFH or OMAP Administrative Rules, payment will not be made to
anyone other than Provider. By accepting payment, Provider certifies that it has complied with all applicable state laws,
federal laws, OPH Tules and OMAP rules.
OHS 1013 (Rev 06/05) Page 1
If Provider is an FQHC, RHC, IHS, or Tribal facility then eligibility for payment shall be made as provided in OFH Rule
333-004-0080, and payment shall be made as provided in OPR Rule 333-004-0110.
Except as otherwise provided in OFH 01' OMAP Administrative Rules, Pl'Ovider accepts, as payment in hill for a claim,
the amount paid by OFH or OMAP for that claim. No dual payment by OFH and OMAP is permitted.
OFH and OMAP have sufficient funds currently available and are authorized to make payments under this Enrollment
Agreement within OFR's and OMAP's biemlal budget. Payment for services performed after this current biennium is
contingent on OFH and OMAP receiving from the Oregon Legislative Assembly appropriations 01' other expenditure
authority sufficient to allow Ol~H and OMAE in its reasonable administrative discretion, to continue to make payments.
Payment for services performed after October 2006 for the Family Planning Expansion Program is contingent on federal
operational authority extending the program past that time.
C. Recordkeeping: Access: Confidentiality of Recipient's Records Provider is responsible for the completion and
accuracy of (1) financial and clinical records and all other documentation regarding the specific care, items or services for
which payment has been requested, and (2) all claims submitted by or on behalf of Provider.
Provider shall furnish requested documentation to OFH and OMAE the Department, the Oregon Department of Justice
Medicaid Fraud Unit, the Oregon Secretary of State's Office and the federal government, and their duly authorized
representatives to examine, audit and make copies.
A Recipient's records are confidential and may be given only to the Recipient, or to others with the Recipient's prior
written consent, or for purposes directly connected with the administration of the public assistance laws.
D. Compliance with applicable laws Provider shall comply with federal, state and local laws and regulations
applicable to this Enrollment Agreement, including but not limited to OAR 333-004-0130 and 410-120-1380. OFH's and
OMAP's obligations under this Enrollment Agreement are conditioned upon Provider's compliance with provisions of
ORS 279B.220, 2798.230, 279B.235, and 279B.270, as amended from time to time, which are incorporated in this agreement.
Provider is responsible for all Social Security payments and federal 01' state taxes applicable to payments under this
Enrollment Agreement.
E. Termination Provider, OFH or OMAP may terminate this Enrollment Agreement without cause at any time by written
notice to the others by certified mail, return receipt requested. This notice shall specify the effective date of termination.
Provider shall send any termination notice to: FPEP Provider Enrollment, 800 NE Oregon Street, Suite 850, Portland,
Oregon 97232, and OMAp, Provider Em-ollment, 500 Summer Street NE, E44, Salem, Oregon 97301-1079.
F. Eligibility alld Continued Participation: Provider sanctions and payment recovery Eligibility and continued
participation in the Family Planning Expansion Program and Medical Assistance Program is conditioned on Provider's
ext!cution anU::delivery of the application and required certification, and the continued accuracy of that information. The
information disclosed by Provider may be subject to verification by OFH or OMAP. This information will be used for
purposes related to the administration of the Family Planning Expansion Program and the Medical Assistance Program.
Failure to comply with the terms of this Enrollment Agreement, the OFH Rules, the OMAP Rules or failure of the
application or certificate to be accurate in any respect may restllt In sanctions, termination of the agreement, or payment
recovery pm:suant to OAR 333-004-0140 through 333-004-0160, and OAR 410-120-1400 through 410-120-1540, subject to
Provider appeal rights described in OAR 333-004-0170 through 333-004-0190 and OAR 410-120-1560 through 410-120
1820.
DHS 1013 (RevOS/05) Page 2
Add explanations or other Information here:
~', l(oHte,". J.).e'S~ Ce>LNrtj ~~~
is Ct p»bliuJv<:aI+A ~I
DHS 1013 (Rev 06/05) Page 3
PROVIDER: By signing this Enrollment Agreement you acknowledge that you have read the En
rollment Agreement, understand the terms of the Agreement, and agree to be bound by the terms
and conditions of the Agreement.
A.7a-v1 W ~ fl-Lr-o::r
Signature of Provider or Au orized Business Representative Date
J)ao 1.(:1 :Be,otot.'1 L..O rot
Printed Name
121 ~c.Ja.e..
Title of Business Representative
ForOFHOnly
State of Oregon, acting by and through the Department of Human Services, Office of Family
Health certifies that the provider is a Family Planning Clinic.
For OMAP Only
State of Oregon, acting by and through the Department of Human Services, Office of
Medical Assistance Programs.
B~
Printed Name: ~7Pr/& .t:::;ee;?Ad.ftJ;-/
Title:~~~.l-r~
Note: OMAP signature is not required if the Provider is an FQHC, RHC, IHS, or Tribal facility.
DHS 1013 (Rev 06/05) Page 4
~t,...".J
",V1uer enrOll .'
Family Planning Clinic Provider Applicatio e istoCT 1'" mGr,~~
f 20B5'
Office of Famil Health OFRD Dn
Received application from provider on:
~Applicant signed agreement in two places ?'Project/Site Number Request Form is complete ~Vt
IZJ License number is included or attached
o CLlA certification is attached ... ")ec C4.ti1 . o Already have active OMAP provider number(s) ..'"
r~!i~~.:~lIl~~i~el~rO~~T~:3
o Approved by OFH as Family Planning Clinic
FyP:P J?rojec~.#: Date a roved:
j Si~~ #__-'__ , .. ___~_tt~.r.!a.!Pe . Site #---+-_.. Site name "
b ---~ -.. ~ K··-----t
; ij i ,,,.---. , .... _--'.. i "",'" .. _. "-,',.,' ,...-.. .·.·,C....,,',·-,..... ~
~
eYTo OFH Administrator for signature: __'()..L7b,,:-tl..:...A~o:...::::~:...-.._______
rYFOlwarded to OMAP on: ___..:..:(0"-f-I"-.f4 5' _........J=-O......_______
-+--
o
Mailed Materials --..-~:
Sent original to OMAP: __________________
OFH contact: Debbi Flittner, 971-673-0363 Phone, 971-673-0231 FAX
OMAP contact: Marta Sandor, 503-945-5792 Phone, 503-947-1177 FAX
OMAP address: 500 Summer St NE, Provider Enrollment 3-44, Salem, OR 97301
DOJ contact: Jeff Wahl, 503-947-4540 Phone, 503-378-4740 FAX
DOJ address: 1162 Court St NE, Salem, OR 97301
Internal Use Only: ATN
Provider Enrollment Request
For Initial Enrollment Only
Identifying Information
Complete all applicable information:
1. Group/Facility or Individual Name:
Last: Deschutes County First: Middle Initial:
2. Individual's Date of Birth: / /
3. Individual's Title/Degree (as appears on license):
4. Doing Business As (DBA) Name: Deschutes County Public Health division
5. Identification Numbers:
DEA Number: EFT Number: NPI: 1023056017
NABP Number: CDS (Controlled Dangerous Substance) Number:
6. License/Certification Information:
License Number: License Type: Certification:
Begin Date: End Date: State:
7. Are you an active Medicare Provider? IllYes D No (If Yes, please indicate your
Medicare Provider lD number.)
Medicare Provider ID number: ROOOOWCGWT
Are you an active Medicaid Provider in another state? DYes III No (If Yes, please
indicate your Medicaid Provider ID number, state and contact information.)
Medicaid Provider ID number and state: 097055 Oregon 320200 Oregon
Medicaid Contact: Nancy Phone Number: 541-322-7516 E-mail: nancy.mooney@deschutes,org
Address Information
Complete all applicable information. If you have additional address/contact
information, please list on an attachment.
Note: A post office box is not a valid service location; the service location address
must be a physical street address.
Provider Enrollment Request OHA 3972 (Rev. 07/11)
Page 1 of 5
la. This address applies to the following locations (check all that apply):
[lJService
Location
[lJPay-To [lI Mail-To DHome
Office
DCorporate
Office
DMedical Information D Personal Residence
Street or PO Box (include Room/Suite):
2577 NE Courtney Drive
I City, State, ZIP:
. Bend, OR 97701
County:
Deschutes
Business Phone:
541-322-7400
Toll-Free Phone:
Fax Number:
541-322-7565
Cell Phone: E-mail:
. International Phone: International Fax: ADA Accessible? DYes D No
1b. Enter the contact information for the address listed in 1 a:
I
1c. If you have more than one service location, please specifY which location( s) the
information listed in 1 a and 1 b should be applied to:
Name:
Nancy Mooney
Contact SSN: Contact DOB:
I Title:
Contract Specialist
Contact Type:
ContractlCredentialing
i
E-mail:
. nancy.mooney@deschutes.org
Phone Number:
541-322-7516
Cell Phone Number:
Fax Number:
541-322-7565
Effective Date: End Date:
2a. This address applies to the following locations (check all that apply):
D Service
Location
DPay-To D Mail-To DHome
Office
DCorporate
Office
DMedical Information D Personal Residence
Provider Enrollment Request OHA 3972 (Rev. 07/11)
Page 2 of 5
Street or PO Box (include Room/Suite): City, State, ZIP:
County: Business Phone: Toll-Free Phone:
Fax Number: Cell Phone: E-mail:
I International Phone: International Fax: ADA Accessible? DYes No
2b. Enter the contact infonnation for the address listed in 2a:
Name: Contact SSN: Contact DaB: •
Title: Contact Type:
E-mail: Phone Number: Cell Phone:
Fax Number: Effective Date: End Date:
2c. If you have more than one service location, please specify which location(s) the
infonnation listed in 2a and 2b should be applied to:
Tax 10 and Social Security Number Information (reporting purposes for payment)
This infonnation must match IRS's infonnation on file.
1. Individual IRS Tax ID Type (check one): D Date of Birth (DaB)
D Social Security Number (SSN)
2. Business IRS Tax ID (FEIN): 93-6002292
3. Business Name associated with IRS FEIN: Deschutes County Oregon
Business Type
1. Indicate all that apply:
D Individual Practitioner D Chain D Trust
Sole Proprietorship III Government DLLC
D Partnership D Intergovernmental DLLP
Provider Enrollment Request OHA 3972 (Rev. 07/11)
Page 3 of 5
Business Corporation: o Private: o For profit 0 Non-Profit o For profit 0 Non-Profit
2. Are you applying as a (select one):
o Individual III Group 0 Facility 0 Organization
3. Group Practice: If you are applying to join an existing group, enter the group's
NPI(s).
4. Provider Type: Using the list on page 5, enter the provider type you are
requesting enrollment as: 22
5. Specialty Information: List below. If you have additional specialty/taxonomies,
please list on an attachment (maximum allowed is 15).
Primary Specialty: Taxonomy:
Sub-Specialty: Taxonomy: Effective Date: End Date:
Sub-Specialty: Taxonomy: Effective Date: End Date:
Sub-Specialty: Taxonomy: Effective Date: End Date:
Sub-Specialty: Taxonomy; Effective Date: End Date:
I
Sub-Specialty: Taxonomy: Effective Date: End Date: !
I
Provider Enrollment Request OHA 3972 (Rev. 07/11)
Page 4 of 5
i
OHA Provider Types
Refer to this list to enter your provider type information on page 4 of this form.
01 Transportation Provider
02 Acupuncturist
I 03 Alcohol/Drug
.05 Ambulatory Surgical Provider
06 Behavioral Rehab Specialist
07 Billing Service
08 Freestanding Birthing Center
09 Billing Provider/Group Clinic
10 Transportation Broker
i 12 Copy Services
13 Cost Based Clinic
14 Rural Health Clinic
15 FQHC
16 Chiropractor
17 Dentist
18 Dental Hygienist
19 Podiatrist
20 Denturist
21 EnterallParenteral
22 Family Planning Clinic
23 Hearing Aid Dealer
24 H H IthAorne ea ,gency
126 Hospital
27 Hospice
28 Indian Health Clinics
29 Independent Labs
30 Mental Health Personal Care
Attendant
.32 End-Stage Renal Disease Clinic
33 Mental Health Provider
34 Physician
35 Oregon State Hospital
36 DMElMedical Supply Dealer
37 Certified Registered Nurse
Anesthetist
38 Advanced Comprehensive Health
Care (Naturopath)
41 Midwife
42 Advance Practice Nurse
43 Optometrist
44 Optician
45 Therapist
46 Physician Assistants
47 Clinic
48 Pharmacy
49 Prenatal Clinic
50 Pharmacist
52 X-Ray Clinic
53 Psychologist Provider
54 Polygrapher
56 Registered Nurse
57 RN 1 st Assistant
58 Registered Dietician
60 Smoking Cessation
62 Education Agency
64 Targeted Case Management
65 Translator
66 Urban Clinic
69 Social Worker
70 Foster Care
71 Child Foster Care
72 SPD Transportation
73 Home Care Worker
74 Client Support Services
75 Case Management
76 County Services
77 Adaptive Modification
78 Habilitation
80 Intermediate Care FacilitylMental
Retardation
81 Nursing Facility
82 SPD Nutritionist
83 Behavioral Consultant
84 Personal Assistant
86 SPD Nursing Services
88 Nursing Agency
89 DD Living Facilities
97 Residential Contract Rates
90 APD Living Residential
91 APD Living Settings
92 Emergency Response (Lifeline)
93 In Home Care Agency
!
Provider Enrollment Request OHA 3972 (Rev. 07/11)
Page 5 of 5
I