Client Referral Form

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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? :


Date of Birth:
To your knowledge, does your client have health insurance?:






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.:

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