Health Related Social Needs (HRSN) Request Form Housing Questions? Call 855-722-8205 Check here if you will be evicted in the next 21 days or less Yes No Member Information Last Name First Name Insurance ID # Date of Birth Address County Polk Washington Yamhill Preferred Language (Optional) Pronouns (Optional) Contact Information Phone Email Primary Care Doctor or Provider Provider Or Doctor Clinic Eligibility Criteria Member must meet ALL the following requirements. If member does not meet HRSN eligibility, consider applying for HRS flex funds: https://yamhillcco.org/wp-content/uploads/YCCO-Flex-Funds-Request-1.pdf You must meet all of the below criteria to qualify: Enrolled in OHP under category CCOA or CCOB (this will appear on your member ID card) Yes No AND Make below 30% of Median Family Income Yes No Family Size Family Income $ AND Currently housed and in AT LEAST ONE (1) HRSN covered population for at risk of homelessness Yes No AND Moved two (2) or more times in the last 60 days because of money Yes No OR Was notified in writing that the right to occupy current housing or living situation will terminate within 21 days Yes No OR Lives in a single-room occupancy or efficiency apartment unit Yes No OR Lives in a Single room unit but resides with more than two (2) persons Yes No OR lives in a larger housing unit with more than 1.5 persons per room Yes No AND Meet AT LEAST ONE (1) of the Housing-Specific Clinical Risk Factors Complex Behavioral Health needs Yes No Developmental Disability Need Yes No Complex Physical Health Need Yes No Need for Assistance with ADLs or eligible for LTSS Yes No Interpersonal violence experienceor LTSS Yes No Adult 65 years of age or older Yes No Child less than 6 years of age Yes No Repeated ED use and crisis encounters Yes No Pregnant/Postpartum Yes No Young Adult with Special health care needs Yes No Type of Needs: (check appropriate boxes) Housing Services: Rent (Maximum of six (6) months) (plus tenancy services) Yes No Utilities (Arrears and set-up) (Maximum of six (6) months) Yes No Name of Landlord Landlord Contact Number Amount per Month $ Number of Bedrooms in home Medically necessary home modifications Yes No Medically necessary home remediations Yes No Storage fees Yes No Hotel/motel fees Yes No Tenancy services Yes No Do you have the following documentation ready? Copy of lease or rental agreement Yes No Proof of income, like tax forms or pay stubs Yes No Agreement from your landlord to accept support or home modification Yes No You can work with any one of our local partners to help you get this documentation, including things like estimates or landlord agreements. Member Attestations (must be completed in full) I am not receiving the same services through other programs, OR my existing service is not fully meeting my needs True False I consent to: Receive approved HRSN Services Yes No Be contacted by phone and text by YCCO staff Yes No Be contacted by phone by the Housing Service Provider, and related contractors or vendors Yes No Be contacted for Housing Care Management (Tenancy Services) (optional) Yes No Expedited- defined as member's life, health, or ability to regain maximum function is in serious jeopardy if determination is not made in the standard time frame. Request must include supporting documentation to substantiate an expedited review. Explanation Additional Comments (Optional) Send
