Patient Referral
Patients are eligible to receive services if they fall within our financial eligibility guidelines and live in our service area. A volunteer staff member will navigate you through the screening process and help you gather documents, if needed. Eligibility is based on an individual’s household income and must be under 275% of the current Federal Poverty Guidelines. All new patients must go through the eligibility screening process and be approved for services before a follow-up medical appointment is made.

Appointments must be scheduled in advance. Please be sure to cancel at least 24 hours in advance if you cannot keep your appointment so that we may see someone else.

Name of Patient *
Address *
Phone number *
Reason For Referral *
Organization Providing Referral
Date of Referral
MM
/
DD
/
YYYY
Person Completing Referral
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