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Client Referral Form
Client Referral Form
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?:
--None--
Yes
No
I am not sure.
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%):
--None--
Yes
No
I am not sure.
Does your client have a language preference? :
--None--
My client prefers English.
My client prefers Spanish.
I am not sure.
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.:
2023 FEDERAL POVERTY LEVELS
Size of
Household
150%
monthly
150%
yearly
200%
monthly
200%
yearly
250%
monthly
250%
yearly
1
$1,823
$21,870
$2,430
$29,160
$3,038
$36,450
2
$2,465
$29,580
$3,287
$39,440
$4,108
$49,300
3
$3,108
$37,290
$4,143
$49,720
$5,179
$62,150
4
$3,750
$45,000
$5,000
$60,000
$6,250
$75,000
5
$4,393
$52,710
$5,857
$70,280
$7,321
$87,850
6
$5,035
$60,420
$6,713
$80,560
$8,392
$100,700
7
$5,678
$68,130
$7,570
$90,840
$9,463
$113,550
8
$6,320
$75,840
$8,427
$101,120
$10,533
$126,400