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Multnomah County Addiction Services: New Client Request
Providers use this form to request a new client entered into CIM by MultCo for A&D Services data. Carrier: Multnomah Other
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* Indicates required question
Email
*
Your email
Person submitting request
*
This person MUST have CIM access to receive notification that the client was created in CIM. If this person does not have CIM access, notification can not be sent to the above email address
Your answer
Submitter's Phone
Phone number of person submitting this form
Your answer
Agency
*
Choose
Bridges To Change
Cascadia
Central City Concern
CODA
CRC Allied Health
FORA Health
Lifeworks NW
Modus Vivendi
NARA
Northwest Family Services
NW Treatment
Project Quest
Volunteers of America
Program
*
Choose
AOP: Adult Outpatient
YOP: Youth Outpatient
DC: DUII Conviction
DD: DUII Diversion
DM: DUII Minor in Possession (MIP)
ARE: Adult Residential (Indigent Only)
OTS: Opioid Treatment Services
COP: CEP Outpatient (CCC Only)
EOP: Esperanza Youth Outpatient (CCC Only)
IOP: Imani Outpatient (CCC Only)
POP: Puentes Outpatient (CCC Only)
ROP: REAL Youth Outpatient (Lifeworks Only)
WM: Withdrawal Management
Requested Enrollment Date
*
MM
/
DD
/
YYYY
Client First Name
*
Your answer
Client MI
Your answer
Client Last Name
*
Your answer
DOB
*
MM
/
DD
/
YYYY
Gender (Legal Gender)
*
Female
Male
Required
OHP#
Your answer
MOTS Provider Number
*
Your answer
MOTS Client Case Number
*
Your answer
Member Phone
Your answer
Address: (If the member is experiencing homelessness, enter "Homeless"; Do not enter agency/facility addresses - ONLY enter the client's address or homeless.)
*
Your answer
City (If homeless and this information is not available, please write in "N/A")
*
Your answer
State (If homeless and this information is not available, please write in "N/A")
*
Your answer
Zip Code (If homeless and this information is not available, please write in "N/A")
*
Your answer
County
*
Multnomah
Other:
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