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Provider request form


All fields must be filled out to be considered for inclusion in the ADRC database. If there are multiple programs within your agency, please complete a Program Application (separately) for each program and an Agency Application for the main administrative agency (i.e. if there are 3 programs under one umbrella agency, complete 4 applications). Incomplete applications cannot be processed.

General Information


*Please review definition of agency vs. program found at the end of this application.
Not Applicable if there is only one agency/program listing.

Location and Contact

8. Physical Address
9. Mailing Address
17. Where do you deliver your service (select all that apply):

Target Population/Program Eligibility


Availability


30. Please provide the point of contact for individuals initially accessing your services.

Cost


32. Please list the funding sources accepted as payment for your services:
If yes, please list insurance accepted:
Please indicate if no one will be denied service for inability to pay.

Quality


(If yes, please include copies of licenses and accreditation certificates with this application.)

Administrative


The following information is required for future updates.

34. Note that the Update Person is the person that is completing this form and/or the person that will be providing information in the future.
(If yes, please include copies of licenses and accreditation certificates with this application.)

ADRC of Oregon is collecting this information to include in a public resource database for community information and referral. This information will be reviewed to ensure the services meet the eligibility for inclusion. We reserve the right to make changes in order to ensure compliance with database style and indexing needs.

*Agency: The agency is the main location of the resource where the administrative functions occur, where the organization's director is generally housed and where it is licensed for business. An agency may or may not deliver direct services from this location.

*Program: We differentiate "programs" from "agencies" when an agency provides a group of unique services, with different sites of operation, eligibility, program contacts, etc. and organizes them as their own "program".

If you have questions or concerns, please contact us by email or call 503-988-8178.

Provider request form

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