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.:

2024 FEDERAL POVERTY LEVELS

Size of Household	150% monthly	150% yearly	200% monthly	200% yearly	250% monthly	250% yearly
1	$1,883	$22,596	$2,510	$30,120	$3,138	$37,656
2	$2,555	$30,660	$3,407	$40,880	$4,259	$51,108
3	$3,228	$38,736	$4,303	$51,640	$5,379	$64,548
4	$3,900	$46,800	$5,200	$62,400	$6,500	$78,000
5	$4,573	$54,876	$6,097	$73,160	$7,621	$91,452
6	$5,245	$62,940	$6,993	$83,920	$8,741	$104,892
7	$5,918	$71,016	$7,890	$94,680	$9,863	$118,356
8	$6,590	$79,080	$8,787	$105,440	$10,984	$131,808

Client Referral Form