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.:

2026 FEDERAL POVERTY LEVELS

Size of Household	200% monthly	200% yearly	250% monthly	250% yearly	300% monthly	300% yearly
1	$2,660	$31,920	$3,325	$39,900	$3,990	$47,880
2	$3,607	$43,280	$4,508	$54,100	$5,410	$64,920
3	$4,553	$54,640	$5,691	$68,300	$6,830	$81,960
4	$5,500	$66,000	$6,875	$82,500	$8,250	$99,000
5	$6,447	$77,360	$8,058	$96,700	$9,670	$116,040
6	$7,393	$88,720	$9,241	$110,900	$11,090	$133,080
7	$8,340	$100,080	$10,425	$125,100	$12,510	$150,120
8	$9,287	$111,440	$11,608	$139,300	$13,930	$167,160

Client Referral Form