Clinic Staff Referral Portal • Saban Community Clinic
Lead Referral Card
Quick Clinic Intake
Clinic & Referring Staff
Clinic Name
Saban Community Clinic
Referring Staff Name
*
Staff Email (for status updates)
Notify me when Marvin contacts patient
Automated status email & notes
Patient / Member Information
Member First Name
*
Member Last Name
*
Date of Birth (DOB)
*
Phone Number
*
Best Time to Reach the Member
Morning (AM)
Afternoon (PM)
Anytime
Medicare & Plan Details
Does the member have Medicare Part A or B?
Yes, Active
Turning 65 / Unsure
No / Not Yet
Medicare ID / Beneficiary Identifier (MBI)
If available
Current Plan (if known)
Primary Clinic Doctor
Desired Plan Details & Benefits Needed
Staff Referral Notes for Marvin Arevalo
Consent to Contact:
"By providing this information, I agree that a licensed health insurance agent representing Stella FMO / Marvin Arevalo may call me to discuss Medicare plan options. I understand this is not required to receive care at this clinic and I may revoke consent at any time."
Member agreed to be contacted
*
Verbal Consent Given By / Signature (Optional confirmation)
Date & time of submission will be recorded automatically for compliance.
Submit Referral to Marvin's CRM
Submission timestamp and clinic source recorded automatically
Advisor Portal Access
Open Advisor CRM & Reports →