Personal Support Worker (PSW) Provider Enrollment Application and Agreement (Revised 08/01/2018)Provider Enrollment Application and Agreement • January 28th, 2022
This Provider Enrollment Application and Agreement (Agreement), sets forth the conditions and agreements for being enrolled as a Medicaid Personal Support Worker (Provider) with the State of Oregon Department of Human Services (DHS), Office of Developmental Disabilities Services (ODDS), and to receive a Provider number to receive payment for services furnished by the Provider to approved Medicaid eligible individuals (Recipients) in Oregon. Payments for services are made using federal Medicaid and state funds.
Personal Support Worker Provider Enrollment Application and AgreementProvider Enrollment 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.
Homecare Worker (HCW) Provider Enrollment Application and AgreementProvider Enrollment Application and Agreement • November 16th, 2022
Homecare Worker (HCW) Provider Enrollment Application and Agreement 居家照護工作者 (HCW) 服務提供者註冊申請與協議書 This Homecare Worker (HCW) Medicaid Provider Enrollment Application and Agreement explains how to do the following 此份居家照護工作者 (HCW) Medicaid 服務提供者註冊申請與協議書說明了如何完成下列事項 • Enroll as a provider with the Oregon Department of Human Services (ODHS) Aging and People with Disabilities (APD) Program and set out HCW compliance obligations 註冊成為俄勒岡州公眾服務部 (ODHS) 老年人與殘障人士 (APD) 計劃的服務提供者並說明 HCW 的合規義務 • Update enrollment information, and 更新註冊資訊；以及 • Receive a provider number. 獲得服務提供者編號。 Note: Providers must have a provider number to be paid for providing services to Medicaid- eligible individuals in Oregon. Federal Medicaid and state funds pay for these services. 註：服務提供者必須擁有服務提供者編號才能在為俄勒岡州符合 Medicaid 資格的人士提供服務時獲得給付。聯邦 Medicaid 與州政府資金負責給付這些服務。 You can get this document in other languages, large print, braille or a format you prefer.Contact APD Provider Relations Unit at 800- 241-3013 or email HCW.Enroll
ContractProvider Enrollment Application and Agreement • January 24th, 2017
In Home Care Agency, Specialized Living Program, Adult Day ServicesMedicaid Provider Enrollment Application and Agreement This Provider Enrollment Application and Agreement, hereinafter referred to as the “Agreement”, sets forth the conditions and agreements for being enrolled as a provider with the State of Oregon Department of Human Services (DHS), Aging and People with Disabilities Division (APD) or Office of Developmental Disability Services (ODDS) and to receive a provider number. The provider number is required to receive payment for Medicaid services furnished by the provider to Medicaid-eligible individuals in Oregon home and community-based settings. Payments for services are made using federal Medicaid and state funds. Type of action requested New enrollment Provider name change: Renewal or re-enrollment of provider number: Revalidation (only when requested by DHS) provider number:
Provider Enrollment Application and AgreementProvider Enrollment Application and Agreement • May 5th, 2020
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
Child Foster Home Medicaid Provider Enrollment Application and Agreement (PEA)Provider Enrollment Application and Agreement • November 15th, 2016
This PEA sets forth the conditions and agreements for being enrolled as a Child Foster Home provider (Provider) with the State of Oregon Department of Human Services (DHS), Office of Developmental Disabilities (ODDS), and to receive a provider number. The provider number is required prior to receiving authorization to provide services to Medicaid-eligible children with intellectual or developmental disabilities in Oregon home and community-based settings and to receive payment for Medicaid services delivered by Provider. Payment for services is made using federal Medicaid and state funds. Complete this PEA in its entirety. If the answer is “none” or “n/a” indicate that in the section.
Provider Enrollment Application and AgreementProvider Enrollment Application and Agreement • September 17th, 2018
This Provider Enrollment Application and Agreement (Agreement), sets forth the conditions and agreements for being enrolled as a Medicaid Personal Support Worker (Provider) with the State of Oregon Department of Human Services (DHS), Office of Developmental Disabilities Services (ODDS), and to receive a Provider number to receive payment for services furnished by the Provider to approved Medicaid eligible individuals (Recipients) in Oregon. Payments for services are made using federal Medicaid and state funds.
In Home Care Agency, Specialized Living Program, Adult Day ServicesMedicaid Provider Enrollment Application and Agreement Revised 05/22/2018 This Provider Enrollment Application and Agreement, hereinafter referred to as the “Agreement”, sets forth the...Provider Enrollment Application and Agreement • November 16th, 2022
County: Phone number: Fax number: Mailing address: City/State/ZIP(+4): Email: Tax ID number (SSN or FEIN): DOB (if applicable): In-Home Agency License number, if applicable: License effective date: License expiration date: Contact name: Contact phone: Contact email:
Homecare Worker (HCW) Provider Enrollment Application and AgreementProvider Enrollment Application and Agreement • November 16th, 2022
Homecare Worker (HCW) Provider Enrollment Application and Agreement 居家护理工作者 (HCW) 服务提供者注册报名申请和协议 This Homecare Worker (HCW) Medicaid Provider Enrollment Application and Agreement explains how to do the following 这份居家护理工作者 (HCW) Medicaid 服务提供者注册报名申请和协议，对如何顺利完成以下各项内容给予了清晰的说明： • Enroll as a provider with the Oregon Department of Human Services (ODHS) Aging and People with Disabilities (APD) Program and set out HCW compliance obligations 注册报名成为俄勒冈州公众服务部 (ODHS) 老年人及残障人士 (APD) 计划的服务提供者，并列明遵守 HCW 的相应义务 • Update enrollment information, and 更新注册报名信息，以及 • Receive a provider number. 领取服务提供者编号。 Note: Providers must have a provider number to be paid for providing services to Medicaid- eligible individuals in Oregon. Federal Medicaid and state funds pay for these services. 注：在俄勒冈州，服务提供者必须拥有一个服务提供者编号，以便在向符合 Medicaid 资格的个人提供服务时获得报酬。联邦 Medicaid 和州政府资金为这些服务支付相应费用。 You can get this document in other languages, large print, braille or a format you prefer.Contact APD Provider Relations Unit at 800-
Provider Enrollment Application and AgreementProvider Enrollment Application and Agreement • July 18th, 2018
This Provider Enrollment Application and Agreement (Agreement), sets forth the conditions and agreements for being enrolled as a Medicaid Personal Support Worker (Provider) with the State of Oregon Department of Human Services (DHS), Office of Developmental Disabilities Services (ODDS), and to receive a Provider number to receive payment for services furnished by the Provider to approved Medicaid eligible individuals (Recipients) in Oregon. Payments for services are made using federal Medicaid and state funds.
