Health-Related Social Needs Form - Advanced Health

Health-Related Social Needs (HRSN) Request Form:


This is a referral form to the Oregon Health Plan "Health-Related Social Needs" program.
To be eligible, you must:
  • - Be an Oregon Health Plan (OHP) member.
  • - Have a health condition that makes extreme heat, cold temperature, poor air quality, or power outage particularly challenging or dangerous for you.
  • - Be in one of the groups listed in Section 2 that puts you at increased risk of poor health.
  • - 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 the Health-Related Social Needs benefits.

Who can complete this form?

  • - You
  • - Parent or Caregiver
  • - A guardian, support, or trusted friend
  • - A staff member from an organization

What needs to be completed?

  • - Please fill out as much of the form as you are willing to do at this time.
  • - Information in section 1 is required to 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.

If you have questions, call Member Services at 541-269-7400