Oregon Department of Human Services, Aging and People with Disabilities and Developmental Disabilities

Rule Rule 411-058-0030
Disclosure Statement

(1) All applicants must file a disclosure statement with the Department upon initial application and for every biannual renewal thereafter. The disclosure statement may be on forms approved and distributed by the Department.
(2) DISCLOSURE STATEMENT: The written disclosure statement must be conspicuous, provided in clear language and include:
(a) A description of the long term care referral to be provided by the referral agent, including the length of any contract the referral agent has with a facility regarding placement information about the client or the subject of placement;
(b) The referral agent’s contact information, including address and phone number;
(c) The referral agent’s privacy policy;
(d) A statement of whether the referral agent provides referrals only to facilities with which the agent has an existing contract; and
(e) A statement of whether the referral fees for the long term care referral will be paid to the referral agent by the facility.
(3) The referral agent must maintain records documenting the provision of the disclosure statement to the client for a duration prescribed in OAR 411-058-0050 (Client Records).
(4) To amend a disclosure statement, a referral agent must file all amended documents and new materials with the Department.
(5) The disclosure may be made orally if the referral agent makes an audio recording of the disclosure with consent of the client and thereafter provides the client with a written disclosure.

Last accessed
Jun. 8, 2021