Critical Medical Needs Form

Valid Referrals: This referral form may be completed by the provider or by an individual (e.g., case workers, community health workers, nurses) with a verifiable relationship to the provider holding a valid NPI number. United Way reserves the right to verify the referral with the provider before proceeding with any assistance.

Directions: Complete this form to refer patients to the United Way Critical Medical Needs Utility Program. If someone other than a healthcare or behavioral health care provider is completing this form, please include your information in fields for the “Preparer”.

Referrals are sent to United Way of Greater Kansas City to determine eligibility for utility assistance programs. (To see a list of service areas covered by this referral form, please refer to this page.) 

To refer someone to the United Way of SW Missouri and SE Missouri please call 417-624-0153. To make a referral for someone in Eastern Missouri or St. Louis please use this form.

Eligibility: To be eligible for the Critical Medical Needs Utility Program, a person must: 

1. Have a critical medical or behavioral health need determined by their provider. 
2. Reside within our service area, which covers much of Western Missouri and the Kansas Metro area.
3. Live in a home with an active Ameren, Evergy, Missouri American Water, or Spire Account.
4. Have a utility disconnection notice or be disconnected from Ameren, Evergy, Missouri American Water, or Spire.

Please contact criticalmedicalneedsintake@uwgkc.org with any questions or concerns.