DIVISION OF MEDICAL ASSISTANCE PROGRAMS /

Substance Use Disorder Residential Treatment Admission/Discharge NotificationForm

Substance Use Disorder Residential Programs: Use this form to report when Oregon Health Plan clients enter or exit your program.
Send the completed form via secure e-mail to DMAP Client Enrollment Services (CES) at .
CONFIDENTIALITY NOTICE: This document contains information which is confidential and/or legally privileged. The information is intended only for the use of the individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any action in reliance on the contents of this information is strictly prohibited. If you have received this document in error, please immediately notify us via secure e-mail at d destroy the documents received. Thank you.

Client information

1 Client Name / 2 Client ID
3 Home Address
4 City State ZIP / 5 Home County
6 Does this client have accompanying dependent child(ren)? / Yes / No
If yes, enter the dependent child(ren)’s name(s):

Notification information

1 Type of Notification (check one): / Adult admission / Adolescent admission / Discharge
2 Contact Person Name and Phone Number
3Name and Phone Number of person who completed this form (if different from Contact Person):

Program information

1 Licensed Program Name:
2 Treatment Program Name and Address:
3 Treatment Program City State ZIP:
4 Provider Billing ID / 5 Program capacity exceeds 16 beds? / Yes / No

Admissions information – Report all admissions within 3 days of admission.

Do not bill DMAP or the CCO/MCO for newly admitted clients until DMAP CES confirms that they have processed your admission notification form. CES will notify you via secure email when this happens.

1 Date of Admission / 2 First Date of Service
3 Projected duration of stay (e.g., 90 days)
4 Current physical health enrollment (check one): / CCO / MCO / FFS
If enrolled in a CCO/MCO, enter CCO/MCO name:
5 Did you notify the CCO/MCO about this admission? / Yes / No / If no, please explain:
6 If program is outside the CCO/MCO’s service area, did you ask the CCO/MCO for an out-of-area referral?
Yes / No / If no, please explain:
7 How was the client referred to you? / Primary care / Court / Self / Outpatient program

Discharge information

1 Date of discharge / 2 Referred to outpatient program? / Yes / No
3 If yes, outpatient program name:

Substance Use Disorder Residential Program

Admission/Discharge Notification Instruction Sheet

Client information

1 Client Name / Name of the person receiving treatment at your facility. Enter as listed on the client’s Oregon DHS Medical ID, Oregon Health ID or Plan ID.
2 Client ID / Enter the 8-digit identifier as listed on the client’s Oregon DHS Medical ID, Oregon Health ID or Plan ID.
3 Home Address / The client’s street address (where they lived prior to entering the treatment program).If the client is homeless, enter “Homeless.”
4 City State ZIP / The city, state and ZIP code of the client’s home address.
5 Home County / The county of the home address (not of the treatment program).
6 Does this client have accompanying dependents? / Check “Yes” or “No.” If the client has dependents residing with him/her at the treatment facility, also provide the dependents’ names.

Notification information

1 Type of Notification / Check “Adult admission,”“Adolescent admission” or “Discharge.”
2 Contact Person Name and Phone Number / This is the person we will contact if we have questions about information on this form.
3 Name and Phone Number of person who completed this form / If there is missing or invalid information on this form, we will contact this person first to ask them to resubmit the form.

Program information

1 Licensed Program Name / This is the name that appears on the actual license issued by AMH.
2 Treatment Program Name and Address / Enter the actual name of the program, if different from the licensed name. Also enter the physical address of the treatment facility.
3 Treatment Program City State ZIP / The city, state and ZIP code of the program’s physical address.
4 Provider Billing ID / Enter your 10-digit National Provider Identifier; or the 6- or 9-digit provider number issued by DMAP.
5 Program capacity exceeds 16 beds? / Programs that exceed 16 AMH-licensed beds are designated “Institutes for Mental Disease” (IMD). If you mark “Yes,” we will ensure that state (not federal) funds reimburse you for services.

Admissions information

1 Date of Admission / Enter the date the client was admitted to the facility for this report period.
2 First Date of Service / Enter the first billable date of service.
3 Projected duration of stay / Tell us how long the treatment plan will be (e.g., 90 days).
4 Current physical health enrollment / Tell us if the client is enrolled with a CCO or MCO, then enter the CCO/MCO name. If the client is enrolled with neither, select “FFS.”
5 Did you notify the CCO/MCO? / To coordinate care with the client’s CCO/MCO, you need to let the CCO/MCO know the client is at your facility. If you have not done this, please explain why.
6 Did you ask for an out-of-area referral? / If your program is outside the CCO/MCO’s service area, you need to coordinate with the CCO/MCO to make sure they will cover this service.If you did not ask for an out-of-area referral, please explain why.
7 How was the client referred to you? / Self-explanatory

Discharge information

1 Date of discharge / Enter the last day the client received treatment in your program.
2 Referred to outpatient program? / Enter Yes or No.
3 Outpatient program name / You must enter this information for all discharges.

SUD Residential Treatment Program Admission/Discharge NotificationDMAP 7204 (Rev. 10/13)