Pilot with Health Begins Now - Referral
Referring Contact Name
*
First Name
Last Name
Referring Contact E-mail Address
*
example@example.com
Referring Contact Telephone
*
Customer Name
*
Customer Address
*
Customer Phone Number (best contact number)
*
Format: (000) 000-0000.
Customer Email Address
example@example.com
Type of assistance needed
*
Rent
Mortgage
Water
Electric
Confirmed the customer is enrolled in the Hillsborough County HealthCare Plan
*
Please Select
No
Yes
Confirmed the customer consents to being referred to Social Services for assistance and is aware they will be contacted to be screened for assistance
*
Please Select
No
Yes
Submit
Follow Up Status - SOCIAL SERVICES STAFF ONLY
Referral Status
Eligible
Not Eligible
Comments
Funding
ERAP
GA
Total GA amount
Appointment Date
-
Month
-
Day
Year
Date
Complete
Should be Empty: