Kivulink — Client Referral Form

Referring Staff Member

Your Name *

Organization (optional)

Your Email *

Your Phone (optional)

Client Information

Client First Name *

Client Last Name *

Client Phone *

Client Email (if available)

Preferred Language (optional)

Household Size (optional)

Est. Annual Household Income (optional)

Reason for Referral

What does the client need? (check all that apply)

Lost Medicaid / Medicaid ending soon Currently uninsured — first-time enrollment Has insurance but needs help with a plan issue or change Interested in life insurance Other (describe below)

Additional Notes (optional)

Best Time to Contact Client (optional)

All client information is handled with full confidentiality and never sold or shared.

Referral Submitted!

Thank you. The Kivulink team will contact your client within 1 business day. A copy of this referral has been sent to your email.

Questions? Call or text (832) 775-2509

Enrollment & Resources

Start ACA Marketplace Enrollment Check Special Enrollment Periods Check If Client Qualifies for Savings

Or scan to open enrollment directly on mobile:

healthsherpa.com — Kivulink enrollment link