Insurance Referral Form
Required documentation for each applicant:
-Photo identification for primary applicant
-Projected total gross income (last 4 pay stubs or letter of verification)
-Tax Return Forms for previous year (if filed)
-Social Security Number for applicant and EACH household member
-Insurance card, cost and term date if ending (if currently insured)
1. This referral form is intended to give Southern Tier Health Care System permission to contact you at your home. It does not enroll in you Medicaid or Child Health Plus.
2. Information covered by signing this referral authorizes Southern Tier Health Care System to disclose insurance information, eligibility screening information, denials, or approvals of insurance programs.
City, State, Zip
Client Email Address
Child Health Plus
Client Request for Medicaid or Child Health Plus
The above listed client wishes to have the opportunity to discuss insurance options and gives permission for a representative of Southern Tier Health Care System to contact them.
Submitted by Name
Submitted by Email Address
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This form was created inside of Southern Tier Health Care System, Inc..