Your social security number and date of birth must be provided for screening in the US Office of Inspector General Exclusion lists, required by OAR 410-172-0610.
To conform to the Oregon Administrative Rules OAR 309-019-0125 and OAR 309-019-0105, Oregon Community Programs requires that this form be completed in order to properly evaluate the education and experience of individuals who wish to be designated as a Qualified Mental Health Associate (QMHA), Qualified Mental Health Professional (QMHP), or a Mental Health Intern. Your response to the inquires in the questionnaire will be used to assess your qualifications for designation as a QMHA, QMHP, or Mental Health Intern. In order to receive your designation, you must have the appropriate degree or alternative, AND demonstrated competencies, AND provide documentation of a successful criminal history records check, as specified by Oregon law (ORS chapter 181 and OAR 407-007-0020 through 407-007-640), AND provide information required for positive clearance from the US Office of Inspector General Exclusion lists, as specified by OAR 410-172-0610.
Please read before completing this application. By completing this form, you hereby authorize Oregon Community Programs and its representatives to consult with agencies, institutions, or organizations, including past and present malpractice carriers and licensing bodies, and past and present employers who may have information bearing on your professional competence, character, and ethical qualifications. You hereby absolve all respondents to your inquiry of any liability for providing relevant information related to your character and your professional qualifications. You certify that the statements you have made are complete and true to the best of your knowledge. You understand that any false statements may be cause for disqualification. You agree to comply with applicable Oregon Administrative Rules. You authorize Oregon Community Programs to complete MHACBO/Certemy and NPPES registrations on your behalf. You will have full ownership of these accounts and will be responsible for changing passwords and updating content if employment at OCP ends.
Upon approval of your credential, you hereby authorize Oregon Community Programs to submit claims and receive direct payments on your behalf. You understand this to be a condition of employment and a requirement per Oregon Administrative Rule 410-120-1260 and federal law 42CFR447.10.
If you need assistance with this application – please contact Alexis Kingston, credentialing@oregoncp.org