Chittenden County Referral Form

SIGN UP/REFERRAL FORM FOR
Addison County - Vergennes Area
If you or a person you know might benefit from SASH, please complete and submit this form OR click the link at the top of the page to download a form you can print, fill out and fax or mail back to us. SASH is a FREE program available to Medicare recipients. (In rare cases SASH may be available to non-Medicare recipients; contact us for information.)
Your Name:
Your Phone Number:

Area CodePhone Number
Your Email Address:
example@example.com
Name of Referring Organization, if applicable:
Name of the Person You Are Referring or Enrolling (the "Enrollee")
Enter "Same" if you are enrolling yourself.
Enrollee's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Why are you referring this person to SASH?
Does Enrollee Have Medicare?
Does Enrollee Have Medicaid?
Enrollee's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Enrollee's Phone Number (including area code):
Enter "Same" if you are signing up yourself.
Your Relationship to the Enrollee:
Enrollee's Primary Care Physician:
Enrollee's Primary Care Location:
Other Services Currently in Place for Enrollee:

Other
Please note: SASH does not provide case management but works with case managers to help meet participants needs.
Please List Contact Information for Agency Support Providers
Date Enrollee Consented to SASH Referral (if applicable):

MonthDayYear
2 digit month, 2 digit day, 4 digit yearLeave blank if you are enrolling yourself.
Should We Contact Enrollee Directly?
Please direct questions to:

Diana Rule-Senzel, SASH Coordinator
50 Armory Lane, Vergennes, VT 05491
Phone: 802-870-7182 | Email: diana@addisonhousingworks.org
Should be Empty: