SOAR Referral Application (General)

The Hillsborough County Health Care Services SOAR (SSI/SSDI Outreach, Access, and Recovery) Referral Application helps determine whether individuals enrolled in or eligible for the Hillsborough County Health Care Plan may qualify for specialized assistance with the SSI/SSDI disability application process.

It may be completed by the client, a service provider, or a case manager and is intended for individuals with serious mental health, medical, or co‑occurring conditions. Experiencing homelessness is not required to apply; however, individuals who are experiencing homeless or at risk of homelessness may qualify for expedited processing through the Social Security Administration.

The application collects key demographic, medical, housing, and benefit-related information and takes about 15 minutes to complete. Please complete it to the best of your ability. After submission, a SOAR Case Manager will contact you within 2–3 business days to review your information, answer any questions, and discuss next steps.

Thank You

Please enter a valid phone number.Format: (000) 000-0000.

First NameMiddle NameLast NameSuffix

Date

Please enter a valid phone number.Format: (000) 000-0000.

List a Landmark, Area, Intersection, or Commonplace

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Facility Name

Street Address

CityState / Province

Postal / Zip Code

Date

Please enter a valid phone number.Format: (000) 000-0000.

Parents, guardian, mother, father, family relatives

List what kind / area, if benign or malignant, has it metastasized (spread), is it operable, what is its current stage

Incl Osteoarthritis, Rheumatoid, Psoriatic arthritis, and Gout

Incl coronary artery disease, arrhythmias like atrial fibrillation, heart failure, and heart valve diseases

Incl Cirrhosis due to Alcohol Abuse; end stage renal failure

Incl epilepsy, grand mal

Appox Date of Last Employment

Type of work or your position / title

Date

SOAR Referral Application

Referral Details

Patient Information

Health Status

Hepatitis A*

Work Status

Currently Employed Full Time

Currently Employed Part Time

SSA Filing Status