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.:

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2022 FEDERAL POVERTY LEVELS

Size of Household	150% monthly	150% yearly	200% monthly	200% yearly	250% monthly	250% yearly
1	$1,699	$20,385	$2,265	$27,180	$2,831	$33,975
2	$2,289	$27,465	$3,052	$36,260	$3,814	$45,775
3	$2,879	$34,545	$3,838	$46,060	$4,797	$57,575
4	$3,469	$41,625	$4,625	$55,500	$5,781	$69,375
5	$4,059	$48,705	$5,412	$64,940	$6,764	$81,175
6	$4,649	$55,785	$6,198	$74,380	$7,747	$92,975
7	$5,239	$62,865	$6,985	$83,820	$8,731	$104,775
8	$5,829	$69,945	$7,772	$93,260	$9,714	$116,575

Client Referral Form