Client Referral Form

Required*

What is today's date?

What is your client's full name?

What is your client's date of birth?

To your knowledge, does your client have health insurance?

Yes No I am not sure

Please provide your client's current address.

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%)

Yes No I am not sure

Does your client have a language preference?

My client prefers English My client prefers Spanish I am not sure

Please describe your client's immediate medical needs and level of urgency.

Please provide your name, organization, contact information and relationship to the client

Please include additional notes regarding this client that would be useful for our team to know.

Size of Household	150% monthly	150% yearly	200% monthly	200% yearly	250% monthly	250% yearly
1	$1,956	$23,475	$2,608	$31,296	$3,260	$39,120
2	$2,644	$31,725	$3,525	$42,300	$4,407	$52,884
3	$3,331	$39,975	$4,442	$53,304	$5,552	$66,624
4	$4,019	$48,225	$5,358	$64,296	$6,697	$80,364
5	$4,706	$56,475	$6,275	$75,300	$7,845	$94,140
6	$5,394	$64,725	$7,192	$86,304	$8,990	$107,880
7	$6,081	$72,975	$8,108	$97,296	$10,135	$121,620
8	$6,769	$81,225	$9,025	$108,300	$11,282	$135,384