HRSN Support Request

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Individuals interested in receiving HRSN Community Services Coordination may fill out this questionnaire. The HRSN Services Coordinator will contact prospective clients in the order questionnaires are received. We expect to start making contact by Monday, December 15th.

Phone

This field is for validation purposes and should be left unchanged.

Are you an active OHP Member?(Required)

You must be an active OHP member, either through a CCO or Open Card to receive HRSN services. If you aren't sure, our Service Coordinator can help you determine your membership status.

What type of OHP card do you have?(Required)

HADCO can only provide support to Umpqua Health Alliance (UHA) CCO members and OHP open card members.

What types of HRSN Housing-related support do you need?

Select all that apply.

Help with rent and utility payments

Help with preventing future eviction or with landlord issues

Help with health-related home modifications

Help finding permanent housing

Other types of housing support not listed

Full Name(Required)

Please enter your name as it appears on your Oregon Health Plan medical card.

First Name Middle Initial Last Name

Mailing Address(Required)

Please enter your complete mailing address.

Street Address City State ZIP Code

Primary Phone(Required)

Please enter the best contact number to reach you. If you do not have a phone number, please enter 000-000-0000.

Message Phone

Please add a secondary or message phone number if you have one available.

Email Address

Please enter an email address where we can send you HRSN-related communications.

Enter Email Confirm Email

When is the best time to contact you?

Please let us know if there are days and/or times that are best to reach you. We will have very limited availability to contact you during evenings and weekends.