Provider Contract Request Form

Provider Contract Request Form

Network/Region*

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Requestor Name*

Requestor Email Address*

Provider/Clinic Name*

Provider Website

Phone Number*

Please enter without spaces or hyphens

Fax Number

Physical Street Address*

City*

Zip*

County*

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If other:

NPI*

TIN*

DMAP ID/Oregon Medicaid Provider ID*

Languages spoken by clinician(s):

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Do you currently offer telehealth services?*

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Do you currently, or do you plan to in the near future, offer in-person services for CareOregon members?*

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Please specify: (languages)

CareOregon members have requested access to more providers with whom they share a culture. Does a clinician currently accepting new clients at this clinic identify as a member of one or more of the groups below:

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If added to our network, how many CareOregon members would you be able to serve in an average month, per clinician?

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How many clinicians?

Do you submit your own claims, or do you work with a third-party billing organization?

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Who?

Have you treated Medicaid-eligible clients in the past, and what is your level of familiarity with Medicaid rules?

Contract Type*

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Physical Health Provider Type*

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If other:

Are you Vaccine For Children (VFC) certified?

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Are you Patient Center Primary Care Home (PCPCH) recognized through the Oregon Health Authority?

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Tier

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Physical Health Specialty(ies):

Behavioral Health Provider Type*

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Behavioral Health Specialty(ies):

Does your clinic have psychiatric provider(s) on staff?*

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If yes, do they prescribe clozapine and/or long-acting injectable (LAI) medications?

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If yes, do they prescribe medication assisted treatment (MAT) for SUDs?

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Clinic runs one of the following certified/fidelity programs:

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Therapeutic Approach

Please indicate specialization of 30 or more hours of training

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Please specify:

Area(s) of Expertise*

Please indicate specialization of 30 or more hours of training

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Session Types Available

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Ages Served*

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Is your agency currently operating under a Certificate of Approval (COA)?*

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