The information you provide to The Rural Health Network of SCNY is used to assist us in referring you to the proper programs, based on that information.  It is not shared with anyone.  If a referral is made, we will only relay information with your permission.

*Name:
*Age:
*Address:
 
*City, State, Zip: ,                 
*Phone:
*County of Residence:
Town of Residence:
*Employment:
*# Residing in household: Adults            Children
*Monthly household income:
*Source of monthly income:
*Gender:
*E-Mail Address:
*Marital Status:
*Housing:
   
*I am seeking:
Health Insurance Prescription Assistance
Vision Dental Care
Transportation Primary Care Provider
Hospital Assistance Other
*Do you have health insurance?
Yes No
  If Yes, what type?
*Prescription Coverage?
Yes No
   
*If you do not have health insurance,
why not?
*Do you have a Primary Care
Physician?
Yes No
  *If Yes, who?    
*Primary Care Physician town?
*If no, where do you seek health
care?
   
Questions/Comments:
*Referral From:
 

*Required Field