Patient Referral for Legal Services

Thank you for reaching out to the VCU Health Medical-Legal Partnership (MLP). By submitting this form, you are requesting our assistance to address legal issues affecting your patient’s health and well-being. Once we receive this form, we will screen the patient/family to determine if the patient qualifies for pro bono legal assistance and if the legal issue is within MLP’s scope of service. We assist patients with most civil legal issues, including housing, public benefits, family law, guardianship, education, immigration, estate planning, consumer, employment, and insurance. We do not provide services in the areas of criminal law or medical malpractice.

Pro bono services through the MLP are intended for low-income patients and families who cannot afford an attorney. Our legal partners use HUD guidelines to determine eligibility: https://www.vhda.com/BusinessPartners/PropertyOwnersManagers/Income-Rent-Limits/Pages/HUDMedianIncome.aspx If you are unsure if the household is eligible, or they are slightly over income but have extenuating circumstances, please submit the referral and MLP staff will follow up. If you have any questions feel free to reach out to us at (804) 517-9110 or mlp@vcuhealth.org.

All patients or guardians are required to sign release of information and client consent forms. Please download the forms, ask the patient or guardian to complete and sign, then attach before clicking ‘Submit’. We cannot submit referrals to our legal partners without these signed forms.

To better assist the patient, please fill out as much information as possible below.

Patient Information

Is the patient a minor?

Is this an urgent issue? (e.g. The family is facing eviction in a matter of days)

Please explain the urgency:

Does the patient have an upcoming court date?

Date

Court

Patient First Name

Patient Last Name

Patient Date of Birth

Month

Day

Year

Patient MRN# (if applicable)

Street Address

City

State

Zip

Responsible Party

Is there a responsible party for this patient?

First Name (of responsible party)

Last Name (of responsible party)

Relationship of the responsible party to the patient

Contact Information

Primary Phone

Alternate Phone

Preferred method of contact

Additional Details

Language

Estimate MONTHLY household income (guess/rough calculation is fine)

Number of adults living in the household

Number of children living in the household

Citizenship Status

Please describe the patient’s legal issue and include any upcoming deadlines or court dates.

Information about the individual making the referral

Referring Clinic Location

Occupation (of the individual making the referral)

First Name (of the individual making the referral)

Last Name (of the individual making the referral)

Email (of the individual making the referral)

Release of Information & Client Consent

Please download, sign, scan, and upload the following forms
Download Forms

Upload Release of Information and Client Consent Form

What to Expect

After you make this referral, MLP staff will follow up with the patient in 1-2 business days. If we have complete information and the HIPAA & Client Consent forms, MLP will make a referral to one of our legal partners. The legal partner will conduct a more in-depth eligibility screening before accepting the case. Once the case has been accepted, the legal partner will work directly with the client to address the issue. If we are unable to reach a patient or family member, our practice is to follow up with you. You may contact the MLP to check on the status of referrals at any time.

Contact Information