Addictions and Mental Health Services

MOTS Registration Request Form

OR Medicaid Provider ID:
OR Medicaid Provider ID: (Optional)
 
Business Name:
DBA: (Optional)
Office Phone:
Ext.: (Optional)
Physical Address:
City:
State:
County:
Zip:
 
System Admin Information
 
First Name:
Last Name:
Email:
Confirm Email:
 
Supervisor Information
 
First Name:
Last Name:
Email:
Confirm Email:

If you need assistance with completing this request form, please email MOTS.Support@state.or.us and MOTS staff will be in contact with you.