Culturally and Linguistically Specific Services Application

Requirement for eligibility of enhanced payment

 
 

This is NOT your NPI number.

 
Phone
 
 
 
 

Fill in the street address.

 
 
 
 
 
 
 
 

Rural is defined as any geographic areas in Oregon ten or more miles from the centroid of a population center of 40,000 people or more.

 

(if you are applying for eligibility as bilingual or sign language provider, please enter none)

 

(if you are applying for eligibility as culturally specific organization, program, or individual provider, please enter none)

 

Must be able to bill for Culturally and Linguistically Specific services or bilingual services, or direct sign language services

 

You must answer all essay questions in full and/or upload relevant certifications.


***Reminder for programs and organizations only, in your attachment, please be sure to include the organization’s or program's culturally specific focus via mission statement, vision statement, or other public-facing document.

Drop your files here
 

Privacy Statement

Information submitted to OHA by applicants for Culturally and Linguistically Specific Services enhanced payment eligibility is considered to be a public record under Oregon’s Public Records Law. This does not necessarily mean that all of the information you submit would be subject to disclosure if OHA received a public records request. Some of the information you submit may be protected from disclosure because it falls within the personal privacy exemption under the Public Records Law. OHA is committed to complying with Oregon’s Public Records Law, and is also committed to protecting the personal privacy of individuals that are required to submit information to OHA, to the extent permitted by the law. In addition, OHA could be required to disclose information you submit if legally required to do so by a subpoena or court order.

 
 

1. The information provided on the application is valid and complete;

2. The agency will comply with the Oregon Administrative Rules that govern these services;

3. If applicable, the agency is compliant with all other licensing or accreditation entities that apply, i.e., Department of Human Services, Drug Enforcement Administration (DEA), etc.


Check the box attesting to all submitted information in the application