Follow the steps to fill out the PA IEB Referral Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by filling out the applicant information section. Provide the first name, last name, recipient ID number, phone number, alternate phone (if applicable), street address, email address, city, state, zip code, date of birth, and social security number. Ensure all information is accurate to avoid any delays.
3. If applicable, check the box to indicate that you wish to contact an additional contact to begin the process. Fill in the additional contact's name or entity, type (such as family member, power of attorney, or social worker), and phone number. Include the signature of the applicant authorizing the sharing of information with this contact.
4. Provide the physician information including the physician’s name, address, phone number, and fax number. This information might be essential for processing the referral.
5. If applicable, complete the nursing home transition program section by including the NHT coordinator's name and agency.
6. Review the completed form for accuracy and completeness. Make sure all required fields are filled out correctly.
7. Once you have filled out the form, save your changes, then download the form for your records and share or print it as needed. You can also choose to send the completed form via fax or secure email.

Complete your PA IEB Referral Form online today to ensure timely processing of your referral.