OHP Housing Benefit Request Form

Health-Related Social Needs Request Form

Section 1: Required Information

I want/need (check all that apply):
Help paying rent for up to six months (including late payments and utilities)
Changes to my home for health and safety. This includes:
  • Adding grab bars, wheelchair ramps, or drawer pulls
  • Deep cleaning
  • Getting rid of pests
  • Installing window blinds

Tenancy support (help getting resources and services that will help me stay housed)

OHP Membership

To get help applying for OHP, click here.
I have OHP/Medicaid.
Yes:  No: 





The best way to contact me is:



The best time to contact me is:
Mailing Address (if available):

Organization Information

If this form is submitted on behalf of the member named above, enter the submitter's information below.

Section 2: Find Out If You Qualify

The below circumstances may qualify you for Housing benefits (check all that apply to you):

I have housing
I have a health condition that requires me to make a fix to my home (see health condition and history below)
I am experiencing one of these life situations:
  • Leaving incarceration (jail, detention, etc.)
  • Recently left a mental health or substance use recovery facility
  • In the Oregon child welfare system (foster care) now or in the past
  • Going from Medicaid-only benefits to qualifying for Medicaid plus Medicare
  • Have a household income that's 30% or less of the average yearly income where I live AND I lack resources or support to prevent homelessness. (You can find a table listing qualifying incomes online.)
Health conditions and history (check all that apply):

I have a complex physical health condition
I have a complex behavioral health condition
I have a developmental or intellectual disability
I have a difficulty with self-care and daily activities
I have experienced abuse or neglect
I use the emergency room or crisis services often
I'm currently pregnant or gave birth in the past 12 months
I'm 65 years or older
The person I am filling this out for is under age 6 years old
I'm not sure
None of the above
Please keep in mind that your application may take up to two weeks to be reviewed, and if approved, more time to receive the service.
What describes your situation now?

My landlord has given me an eviction notice, and I need support in less than two weeks
I don't have an eviction notice, but my bills are due in less than two weeks
Not sure
None of the above

Statement of Truth

By submitting this form, I understand and agree that:

  • I want Advanced Health to find out if I qualify for the services I marked above.
  • Advanced Health may contact me to get more information about this request.
  • To the best of my knowledge, all the information I gave in this request is true, correct, and complete.
  • If I give information that is not true I may have penalties under state or federal law. This may include paying back money spent on any services I get because of this request.