Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Review the header information on the form, including the instructions on how to submit the completed form via fax or secure email. Ensure you understand how to initiate secure email if you are sending sensitive information.
3. Fill out the 'Applicant Information' section with details such as the name, recipient ID number (if applicable), date of birth, social security number, street address, city, state, zip code, email address, and phone numbers.
4. If you wish to correspond with additional contacts rather than the applicant, provide their names and contact information in the ‘Additional Contacts’ section. Make sure to select the appropriate contact type and obtain necessary signatures.
5. Complete the 'Referral Made By' section with your name, agency, and contact information. Ensure that you indicate whether you have confirmed the individual's request to initiate an application.
6. Include the 'Physician Information' section, providing the physician's name, street address, city, phone number, and fax number, if relevant.
7. If applicable, fill out the 'Nursing Home Transition Program' section, including the NHT coordinator's name and agency details.
8. Once all fields are filled out, review the form for accuracy and completeness. Make any necessary corrections.
9. Save your changes, and then download, print, or share the completed form as necessary, ensuring that you choose a secure method if it contains protected information.

Start filling out the PA IEB Referral Form online today to refer an individual for necessary services.