Culturally and Linguistically Specific Services Application

Requirement for eligibility of enhanced payment

Organization, Program or Provider Name

MMIS Medicaid Number

This is NOT your NPI number.

Phone Number

Phone

NPI Number

Contact Name

Contact Email Address

Address Where Services Are Provided

Fill in the street address.

City

State

Zip Code

County

Provide number of people on staff

Number of people served annually

Do you serve children and families?

Yes

Are you a rural provider

Rural is defined as any geographic areas in Oregon ten or more miles from the centroid of a population center of 40,000 people or more.

Yes

Enter the distinct minoritized culturally specific community served

(if you are applying for eligibility as bilingual or sign language provider, please enter none)

If you are applying as a bilingual provider, enter the language spoken

(if you are applying for eligibility as culturally specific organization, program, or individual provider, please enter none)

Qualification Type - (Narrative element questions to follow)

Must be able to bill for Culturally and Linguistically Specific services or bilingual services, or direct sign language services

Culturally and Linguistically Specific Services Organization (460)

Culturally and Linguistically Specific Services Program (459)

Culturally and Linguistically Specific Services Individual Provider (461)

Individual Bilingual Provider (462)

Individual Sign Language Provider (463)

Attach Documents Here

You must answer all essay questions in full and/or upload relevant certifications.

***Reminder for programs and organizations only, in your attachment, please be sure to include the organization’s or program's culturally specific focus via mission statement, vision statement, or other public-facing document.

Drop your files here

Privacy Statement

Information submitted to OHA by applicants for Culturally and Linguistically Specific Services enhanced payment eligibility is considered to be a public record under Oregon’s Public Records Law. This does not necessarily mean that all of the information you submit would be subject to disclosure if OHA received a public records request. Some of the information you submit may be protected from disclosure because it falls within the personal privacy exemption under the Public Records Law. OHA is committed to complying with Oregon’s Public Records Law, and is also committed to protecting the personal privacy of individuals that are required to submit information to OHA, to the extent permitted by the law. In addition, OHA could be required to disclose information you submit if legally required to do so by a subpoena or court order.

Name of the person who is attesting to the information submitted

I understand and attest that the information I submit to Oregon Health Authority is true accurate and complete.

1. The information provided on the application is valid and complete;

2. The agency will comply with the Oregon Administrative Rules that govern these services;

3. If applicable, the agency is compliant with all other licensing or accreditation entities that apply, i.e., Department of Human Services, Drug Enforcement Administration (DEA), etc.

Check the box attesting to all submitted information in the application

I understand and attest that the information I submit to Oregon Health Authority is true accurate and complete.

Send me a copy of my responses

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