Santiam Service Integration Funding Request

Funding Request Form

Welcome to Santiam Service Integration Funding Request Form. We value our partners and are thankful Santiam Families have advocates such as you! If you have questions about this form or need assistance filling it out please contact Melissa Baurer, Santiam SI Coordinator, mbaurer@santiamhospital.org or 503-769-9319

Basic Funding Guidelines

Service Integration Team dollars are intended to meet an immediate one time need that achieves a measurable outcome towards health, wellness, and/or self-sufficiency. SIT funds are a last resort when all other community resources have been accessed or unavailable.

The online request form is intended for community partners and service providers only. If you are needing assistance with a personal need please contact The Salvation Army (503-585-6688) or Marion County Resource Center (503-399-9080).

Measurable Outcomes

Service Integration funds should be focused on meeting needs that can provide some measurable outcome (whether big or small).

Before submitting a request please read the Service Integration Funding Process Form and Service Integration Funding Guidelines which are found on the website: www.santiamhospital.org/sit.php

Question Title

* 1. Please upload the Release of Information (one is required to be signed prior to an advocate completing the funding request). If you need a blank copy of a Release of Information please email mbaurer@santiamhospital.org requesting one or visit www.santiamhospital.org/sit/php

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 2. Referring Agency/Provider

Your name

Agency

Email Address

Phone Number

Question Title

* 3. Client Information

Name

Address

City

Phone number

Preferred language

Question Title

* 4. Please designate the team(s) from which you are requesting funds.

North Santiam (Stayton, Sublimity, Lyons, Mehama)

Cascade (Aumsville, Turner, Community of Marion, and part of Salem)

Santiam Canyon (Idanha, Gates, Mill City, Detroit)

Question Title

* 5. Amount requested

Question Title

* 6. By when is the funding needed?

Date

Santiam Service Integration Funding Request

Funding Request Form

Question Title

* 1. Please upload the Release of Information (one is required to be signed prior to an advocate completing the funding request). If you need a blank copy of a Release of Information please email mbaurer@santiamhospital.org requesting one or visit www.santiamhospital.org/sit/php

Question Title

* 2. Referring Agency/Provider

Question Title

* 3. Client Information

Question Title

* 4. Please designate the team(s) from which you are requesting funds.

Question Title

* 5. Amount requested

Question Title

* 6. By when is the funding needed?

Question Title

* 7. Type of request