Patient Questionnaire

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Patient Questionnaire

Confirmation – your form has been successfully submitted!

Thank you for completing the JaxCareConnect Patient Questionnaire. Your information has been received and will be reviewed by our Intake Team.

What Happens Next?

An Intake Specialist will contact you within 2 business days to:

  • Review your submitted information
  • Confirm eligibility for services
  • Discuss your healthcare needs and next steps

 

You may receive outreach by phone call, text message, or email from our team. Calls may come from 904-595-7770. Please be sure to check your voicemail, spam, and junk folders as well.

Once eligibility is confirmed, you may be connected with a Patient Health Advocate (PHA) who can assist you in connecting to primary care services and other resources that best fit your needs. We understand that navigating care and community resources can sometimes feel overwhelming, and our team is here to help guide and support you through the process.

Important Reminder

Responding promptly helps us move your referral forward as quickly as possible. If we are unable to reach you after multiple outreach attempts, your referral may be closed until we hear back from you.

If you have any questions regarding your submission, please contact our team directly at 904-595-7770.

Thank you for taking the first step toward improving your health and access to care.

JaxCareConnect

Fields marked * are required



Date of Birth:
Do you have health insurance? :
Do you have a primary care doctor? :






What is your family size? (Include yourself, your spouse/partner, children under 18, students under 21, and unborn children) :
Are you employed?:
What is your estimated household income for the past 4 weeks? :
Please describe your most immediate needs and level of urgency:
Are you the patient completing this application or are you completing this application for someone else? :
Is there anything else we should 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