FormsIowa Department of Health & Human Services 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Member Information section. Enter the member's name, date, address, city, state/ZIP, telephone, cell phone, state ID, and date of birth.
3. Proceed to each question regarding the individual's medical conditions. For each category (e.g., disabling mental disorder), check 'Not Applicable' if it does not apply or mark the appropriate diagnosis if it does.
4. In Box 7, describe any activities of daily living (ADLs) that the member needs assistance with and specify how often assistance is required.
5. Complete the Provider, Worker, or Referring Entity Information section. Ensure you include your agency name, your name as the individual completing the referral, your NPI/license number, telephone number, and email.
6. Finally, review all entries for completeness and accuracy before signing and dating the form. Use the ‘Submit Referral Form’ button to submit electronically.

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