Health Share of Oregon — Social Needs Request Form

We are currently experiencing a high volume of requests & calls that may delay response time. Please allow us 7-10 business days before following up on your request.

If you currently have a court-ordered eviction notice, utility shut-off notice, or disconnected service, please call 211info at 503-468-5375 instead of submitting a request form below.

To be eligible to receive assistance, all of the following must be true:

• They must be a current member
• They are not able to get the item/service through any other benefit or means
• The item or service must help with their medical need and/or life situation, and
• They provide all required documentation for the request

Please have the following documentation easily accessible/prepared in advance to support the timely processing of your request, as relevant:

• Rental/lease agreement
• Court-ordered eviction notice
• Utility bill (such as electricity, natural gas, internet, water, sewer, garbage, cell phone, landline)
• Shut-off notice for utilities
• Storage unit bill

Not all requested items or services are granted/funded. Our team evaluates each request on a case-by-case basis and makes the final funding determination, including the amount(s) of funding rewarded if members meet eligibility criteria.

Please review the following Social Needs Assistance Guidelines for more information about qualifying medical conditions and life situations and the commonly funded supports for each.