Chittenden County Referral Form

SIGN UP/REFERRAL FORM FOR
Rutland County
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 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
Date
Does Enrollee Have Medicare?*

YesNo
Does Enrollee Have Medicaid?*

YesNo
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:

Agency on AgingMental Health SupportHome Health Skilled NursingMeals on WheelsHomemaker/Personal CareOther
Please List Contact Information for Agency Support Providers
Date Enrollee Consented to SASH Referral (if applicable):

MonthDayYear
Leave blank if you are enrolling yourself.
Should We Contact Enrollee Directly?*

YesNo
Please direct questions to:

Carol Keefe, SASH Program Manager

5 Tremont Street, Rutland, VT 05701

Phone: 802-775-2926 x16 |Email: ckeefe@rhavt.org
Should be Empty: