Developmental Disabilities Independent Provider Enrollment Application and AgreementEnrollment Application and Agreement • October 20th, 2016
This Provider Enrollment Application and Agreement (the Agreement) sets forth the conditions and agreements for being enrolled as a Medicaid Independent Provider (non-PSW; hereinafter referred to as Provider) with the Department of Human Services (DHS). Under the terms of this Agreement, the Provider will receive a Provider number, as required in order to receive an authorization for services, submit payment claims, and to receive payment for Community Service Payments. Community Service Program services are provided to persons with intellectual or developmental disabilities (hereinafter referred to as Recipients). Payments for services are made using federal Medicaid or State of Oregon funds or a combination of both state and federal funds.
Provider Enrollment Application and AgreementEnrollment Application and Agreement • March 9th, 2015
This Provider Enrollment Application and Agreement “Agreement,” sets forth the conditions and agreements for being enrolled as a provider with the State of Oregon Department of Human Services (DHS), Office of Developmental Disabilities Services (ODDS) and to receive a provider number in order to receive payment for services furnished by the provider to approved service recipients in Oregon. Payments for services are made using federal Medicaid and state funds.
Enrollment Application and AgreementEnrollment Application and Agreement • September 20th, 2016
Mother or Legal Guardian Father or Legal Guardian Street Address Street Address City/State/Zip City/State/Zip Home Phone Cell Phone Home Phone Cell Phone Employer Employer Employer Address Employer Address Employer Phone Ext. Employer Phone Ext. Primary Email Address Primary Email Address
1stChild Date of Birth Male_ Female_Enrollment Application and Agreement • August 12th, 2015
Full Address _ Home Phone Alternate Phone Date attendance will begin e-mail address Normal attendance will be approximately a.m. to p.m. on the following days:
ENROLLMENT APPLICATION AND AGREEMENTEnrollment Application and Agreement • December 20th, 2021
MY CHILD IS CURRENTLY ON MEDICATION( S) PRESCRIBED FOR LONG TERM CONTINUOUS USE AND/ OR HAS THE FOLLOW ING PRE- EXISTING ILLNESS, HEALTH CONDITONS, MENTAL CONCERNS OR DIETARY RESTRICTIONS:
Personal Support Worker Provider Enrollment Application and AgreementEnrollment Application and Agreement • April 23rd, 2021
This Provider Enrollment Application and Agreement “Agreement”, sets forth the conditions and agreements for being enrolled as a provider with the State of Oregon Department of Human Services (DHS), Office of Developmental Disabilities Services (ODDS) and to receive a provider number in order to receive payment for services furnished by the provider to approved service recipients in Oregon. Payments for services are made using federal Medicaid and state funds.
1stChild Date of Birth Male_ Female_Enrollment Application and Agreement • May 14th, 2020
Full Address _ Home Phone Alternate Phone Date attendance will begin e-mail address Normal attendance will be approximately a.m. to p.m. on the following days:
