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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

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:
9. Mailing Address
Street Address:
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 No
16. Are you located on a bus line?
Yes No
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 No
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.)


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 No
28. Can service providers refer directly?
Yes No
29. Is there currently a waitlist for services?
Yes No
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:


31. Please list the cost of services. If the scholarships/financial aid are available, please indicate how consumers can apply.
32. Please list the funding sources accepted as payment for your services:
Yes No
Auxiliary Grants?
Yes No
Veterans Administration?
Yes No
Do you accept Medicaid?
Yes No
Do you accept Medicare?
Yes No
Private Insurance?
Yes No
If yes, please list insurance accepted:
Private Pay?
Yes No
Do you currently offer sliding scale fees?
Yes No
Please indicate if no one will be denied service for inability to pay.


33. Is your facility licensed or accredited?
Yes No

Licensing Body:
License Date:
License #:
(If yes, please include copies of licenses and accreditation certificates with this application.)


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:
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 503-988-8178.

Provider request form


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