PacificSource Health Related Services

This is a referral form to the Oregon Health Plan (OHP) Health-Related Social Needs (HRSN) program.

To be eligible, you must:

• Be an OHP member.
• Have a health condition that makes extreme heat, cold temperature, poor air quality, or power outages particularly challenging or dangerous for you.
• Be in one of the groups listed in Questions 15 and 16 of the form below that puts you at increased risk of poor health. (Scroll down for the complete list of covered groups.)
• Currently need a heater, air conditioner, air filter, mini-refrigerator for medications, or a portable power supply.
• Request the service and agree to share your information to see if you are eligible.

Your health plan will review this form to connect with you and determine whether you are eligible for HRSN benefits.

Who can complete this form?

• You
• Parent or guardian

A caregiver, friend, or a staff member from an organization may also help you complete this form. Please note that you or your parent/guardian must sign the consent to receive services at the bottom of the form.

What needs to be completed?

• Please fill out as much of the form as possible.
• The information in Questions #1-14 must be completed before submitting the form. Your health plan will contact you to complete the process.
• There is a standard limit of one climate device type per household. However, exceptions may be made based on individual circumstances. If you are requesting climate-related equipment for more than one member of your household, please fill out a HRSN Request Form for each person.

Questions?

For questions, please call PacificSource at 541-284-7964 or send an email to HealthRelatedServices@PacificSource.com.