Client Referral Form

Confirmation – your form has been successfully submitted!

Thank you for submitting a Client Referral Form. The individual you referred should be contacted by a Patient Health Advocate within the two business days. If you have any questions regarding your submission, please don’t hesitate to call our direct line at 904-595-7770.

Fields marked * are required

What is today's date? :
Client First Name
Client Last Name
Date of Birth:
To your knowledge, does your client have health insurance?:
Client's Street
City
State/Province
Zip
Please provide a phone number for your client*
Please provide an email address for your client
To your knowledge, is your client at or below 200% of the 2021 Federal Poverty Guidelines? (in some cases, patients are still eligible up to 250%):
Does your client have a language preference? :
Please describe your client's immediate medical needs and level of urgency. :
Referrer's Name*:
Referrer's Organization*:
Referrer's Phone*:
Referrer's Email*:
What is your relationship to the Client?:
Please include additional notes regarding this client that would be useful for our team to know.:

2025 FEDERAL POVERTY LEVELS

Size of Household	200% monthly	200% yearly	250% monthly	250% yearly	300% monthly	300% yearly
1	$2,608	$31,296	$3,260	$39,120	$3,912	$46,944
2	$3,525	$42,300	$4,407	$52,884	$5,289	$63,468
3	$4,442	$53,304	$5,552	$66,624	$6,663	$79,956
4	$5,358	$64,296	$6,697	$80,364	$8,037	$96,444
5	$6,275	$75,300	$7,845	$94,140	$9,414	$112,968
6	$7,192	$86,304	$8,990	$107,880	$10,788	$129,456
7	$8,108	$97,296	$10,135	$121,620	$12,162	$145,944
8	$9,025	$108,300	$11,282	$135,384	$13,539	$162,468

Client Referral Form