Benefits Enrollment Referral Form Client Name * First Name Last Name Phone * (###) ### #### Email Service(s) Needed SNAP (food security) MassHealth Prescription Advantage Medicare Savings Program LIHEAP (Low Income Home Energy Assistance Program) Referring Agency/Comment Which city/town/neighborhood does this client reside in? * Thank you for submitting a referral!Please note that it may take up to 2 weeks from completion of this form to get an appointment.Have a great day! Made Possible by a grant from: This institute is an equal opportunity provider..