HRSN Home Modification/Remediation Request Form

  • Polk County Family & Community Outreach - Call for Contractors!

    Are you a contractor that is licensed, bonded, and insured in the State of Oregon? Can you install ramps, door or cabinet door handles? Can you provide house cleaning, junk removal, or pest control? Please complete the form to indicate you are interested in partnering with Polk County Family and Community Outreach to provide these services to approved clients.
  • Format: (000) 000-0000.
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  • What services can your business provide (please check all that apply)?*
  • Would you be able to travel to various cities in Polk County (please check all that apply)?*

  • Overview of how the process would go

    • Our team will meet with the client to discuss their need
    • If client indicates they are interested in the HRSN Home Modification and/or Home Remediation benefits, we will contact a contractor to complete a walkthrough at the clients home and complete a Scope of Work
    • If additional information or a separate quote needs to be provided, that is okay.
    • Polk County will need a W-9 from the business in order to issue a check
    • HRSN caseworker will help the client apply for the HRSN benefit
    • The clients insurance provider will review their application and the Scope of Work to approve or deny their application
    • If the application is approved, the HRSN caseworker will cooridnate the delivery of the service
    • After the service is completed, a final receipt will need to be submitted to the HRSN caseworker
    • The HRSN caseworker will send a Promise to Pay to the appropriate individual which will state that the business will receive a check from Polk County within 2-3 weeks. 

  • Please click here to learn more about Health-Related Social Needs (HRSN) Program through the Oregon Health Authority.

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