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Help Your Clients and Patients Access More Than Healthcare.

Healthcare providers and community organizations can refer individuals and families to CBS for free benefits enrollment assistance and connections to essential community resources.

Complete the form below to refer a client.

CBS Refer A Client Form

Medi-Cal / CalFresh / Health Access Program (HAP)

Do not include Social Security Numbers on this form.

  1. Referral Source
  1. Client Referral Information
  1. Program Requested
Select all that apply
  1. Client Indentifying Information
Date of Birth
Month
Day
Year
Gender
Housing Situation
Us citizen
Yes
No
Marital Status
Single
Married
Divorced
Background
  1. Documents You May Be Required to Provide

This list is for reference only. Depending on the program, clients may be asked to provide certain documents. You do not need to submit these documents at this time. CBS will advise you of the specific documents required for your selected program.


Proof of Identity

  • Driver's licence or State ID

  • Permanent Resident Card (both sides) or U.S. Passport

  • Social Security Number (SSN), if requested


Proof of Income

  • Paystubs from the past 30 days

  • Award letter (unemployment, disability, Social Security)

  • Child support check

  • Bank statement

  • Retirement or pension statement

  • Vehicle registration


Proof of Expenses

  • Rental agreement or rent receipt

  • Mortgage bill

  • Motel receipt

  • Utility bill

  1. Additional Caseworker Comments
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