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DMAP Forms
Forms are in PDF format.
300 Series
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DMAP 340
Pharmacy Registration for Senior Prescription Drug Assistance Program
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DMAP 390
Request to Change Pharmacy
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400 Series
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DMAP 405T
Medical Transportation Order
DMAP 406
Medical Transportation Eligibility Screening and Medical Transportation Order
DMAP 409
Medical Transportation Screening/Input Document
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DMAP 410
Medical Transportation Screening Documentation
DMAP 473
Request for PCCM Enrollment Override
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500 Series
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DMAP 505
Medicare/Medicaid Billing Invoice (continuous)
DMAP 590
Private Duty Nursing Psychosocial Grid
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DMAP 591
Private Duty Nursing Acuity Grid
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1000 Series
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DMAP 1036
Individual Adjustment Request
DMAP 1038
Register your NPI with OMAP
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DMAP 1074
Prior Authorization for Out-of-State Services
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1200 Series
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DMAP 1274
Home Health Payment Authorization Request
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1400 Series
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DMAP 1480
OMAC Dispute Resolution and Research Request
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2400 Series
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DMAP 2405
Service Denial Notification
DMAP 2410
Newborn Notification
DMAP 2420
DMAP Forms Request
DMAP 2461
Evaluation of Respiratory Assist Device
DMAP 2470
Maternity Case Management - Initial Assessment
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DMAP 2471
Maternity Case Management - Training and Education Tracking
DMAP 2472
Maternity Case Management - Home and Environmental Assessment
DMAP 2473
Maternity Case Management - Five A's Intervention Record (FAIR) for Smoking Cessation
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3000 Series
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DMAP 3027
FQHC/RHC Cost Statement; also in MS Excel
DMAP 3030
Notice of Hearing Rights
DMAP 3035
Provider Information Update
DMAP 3047
Augmentative Communication Device Selection Summary Report
OMAP 3073
Premium Referral for Private Health Insurance
DMAP 3077
Direct Deposit Authorization form
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OMAP 3079
Notice of TPO Exemption to HIPAA Privacy Requirements
DMAP 3082
Overview of Services for Children in Foster Care
DMAP 3083
Subsidized Adoptions - Reimbursement Request
OMAP 3084
Request for Transplant Evaluation
DMAP 3086
Subsidized Adoptions - Prior Authorization Request
DMAP 3089
Authorization for Home Enteral/ Parenteral/ Nutrition and IV Services
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| 3100 Series - Other forms |
DMAP 3130
Primary Care Manager Application
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DMAP 3155
Positioner Justification - Positioners for Standing |
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3200 Series
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DMAP 3274
Outreach Quarterly Report to OMAP
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9000 Series
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DMAP 9033
Lead Risk Assessment Questionnaire
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Miscellaneous
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DHS 791 - New!
Transitional Payment Request
Form 42
Hospital Cost Settlement form - Excel template
Form 42 instructions
Cost settlement form instructions - Word document
DHS 3970
EDMS Cover Sheet
DHS 3971
Oregon DHS Prior Authorization Request
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MAC Local Match Leveraging Form:
(Word or PDF )
For providers who invoice DMAP for Medicaid Administrative Claiming (MAC) activities.
MMIS Local Match Leveraging Form
(Word or PDF )
For School-Based Health Services, Behavioral Rehabilitative Services, and Targeted Case Management
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