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
-Email Address
-Insurance card, cost and term date if ending (if currently insured)
Special Note:
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.
Name *
Your answer
Phone Number *
Your answer
Mailing Address *
Your answer
City, State, Zip *
Your answer
Client Email Address
Your answer
Insurance Type
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 *
Your answer
Submitted by Email Address *
Your answer
Referral Agency
Your answer
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