Oregon Health Plan Interest Form

Oregon Health Plan Interest Form

Oregon Health Plan provides health care coverage to low-income individuals and families, making sure they can access basic health care needs.
In what language do you prefer to receive communications? / En que idioma prefiere comunicarse?

EnglishEspañol
Puede traducir este formulario con la bandera de idiomas en la esquina derecha.
Date

MonthDayYear
Date
Check what you need assistance with (Check all that apply):*

OHP New client applicationOHP RenewalCoverage Active or InactiveOther OHP Question or helpFoodHousingReferrals to other programs outside of OHPOther
Referred by (agency or person):
First and last name of person requesting an appointment:*

First NameLast Name
Date of Birth of Primary Applicant*

MonthDayYear
Email address:*
Do you speak English?*

YesNo
If not, what language do you prefer?
Language
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Are you able to send and receive via text messages to communicate with assister?*

YesNo
How many people are you requesting to apply for OHP?*
Claimed on Taxes
Click here for to read about your rights and responsibilities for OHA assistance.
Haga clic aquí para leer sobre sus derechos y responsabilidades para la asistencia de OHP.
I have read and understand my Rights and Responsibilities*

I Agree
Name*

First NameLast Name
Date*

MonthDayYear
Date
Thank you for submitting an interest form, someone will contact you in the order received. For any questions, contact information is below:

Elena Sierra, Application Assister Specialist

2303 SW 1st street, Redmond, OR 99756

Direct phone: 541-323-6552

Fax: 541-504-5725

elenas@neighborimpact.org
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