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Provider Request Form

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

1. Agency Name:

*Please review definition of agency vs. program found at the end of this application.

2. Program Name:

Not Applicable if there is only one agency/program listing.

3. Other name(s) program may be known by (AKA):

4. Program Description and services offered:

5. Legal Status (Private, Non-profit, Public, etc.):

6. Web Address:

7. Alt Web Address:

Location and Contact

8. Physical Address

Street Address:

City:

Zip:

County:

9. Mailing Address

Street Address:

City:

Zip:

County:

10. Main Phone:

11. Alt Phone:

12. Fax:

13. TTY/TDD:

14. Additional Telephone (please describe)

15. Is Your Facility ADA (Americans with Disabilities Act) Compliant?

Yes, Fully

Yes, Partially

16. Are you located on a bus line?

Yes, Fully

17. Where do you deliver your service (select all that apply):

On-Site

Consumers Home

Telephone

Website

In the Community

18. Area Served (Please indicate the City/County/State of program service area):

Target Population/Program Eligibility

19. Ages Served:

20. Languages Spoken on Site:

21. Do you use an interpreter service?

Yes

22. Target Population (Who are your services for?):

23. Other Eligibility Requirements (i.e. Documentation needed to access services; Income verification; Referral(s) required, etc.)

Availability

24. Hours of Operation (please include administrative and service delivery hours):

25. Please describe the service Application/Intake Process:

26. When can consumers expect to be contacted?

27. Can consumers self refer?

Yes

28. Can service providers refer directly?

Yes

29. Is there currently a waitlist for services?

Yes

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

Intake Contact Name:

Intake Contact Title:

Intake Contact Phone:

Intake Contact Email:

Cost

31. Please list the cost of services. If the scholarships/financial aid are available, please indicate how consumers can apply.

Quality

33. Is your facility licensed or accredited?

Yes

Licensing Body:

License Date:

License #:

(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.

Update Person Name:

Title:

Update Person's Email:

Update Person's Phone:

(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 Tel: 503-988-8178.