NC DSB-4002-ILR 2007-2025 free printable template

This document is a referral form used by the North Carolina Department of Health and Human Services for individuals seeking Independent Living Rehabilitation services through the Division of Services for the Blind. It captures essential information such as personal details, disabilities, economic need, rehabilitation history, and employment goals.

How to fill out referral form

How to fill out referral form

1. Obtain the referral form from the relevant office or website.
2. Fill in the patient's personal information, including name, address, and contact details.
3. Provide details about the medical condition that requires referral.
4. Include the referring physician's information, such as name and contact.
5. Specify the type of specialist needed for the referral.
6. Attach any relevant medical records or documentation.
7. Review the form for accuracy and completeness.
8. Submit the completed referral form to the appropriate office or specialist.

Who needs referral form?

1. Patients requiring specialized medical assistance.
2. General practitioners referring patients to specialists.
3. Healthcare facilities processing referrals for patient care.
4. Insurance companies for authorization of specialist visits.

For pdfFiller’s FAQs

How can I manage my referral form directly from Gmail?

The pdfFiller Gmail add-on lets you create, modify, fill out, and sign referral form and other documents directly in your email. Click here to get pdfFiller for Gmail. Eliminate tedious procedures and handle papers and eSignatures easily.

How do I make edits in referral form without leaving Chrome?

Add pdfFiller Google Chrome Extension to your web browser to start editing referral form and other documents directly from a Google search page. The service allows you to make changes in your documents when viewing them in Chrome. Create fillable documents and edit existing PDFs from any internet-connected device with pdfFiller.

How can I edit referral form on a smartphone?

The pdfFiller apps for iOS and Android smartphones are available in the Apple Store and Google Play Store. You may also get the program at https://edit-pdf-ios-android.pdffiller.com/. Open the web app, sign in, and start editing referral form.

What is referral form?

A referral form is a document used to refer an individual or case to another professional, department, or organization for additional assistance or evaluation.

Who is required to file referral form?

Typically, professionals such as healthcare providers, social workers, or educators who identify the need for additional services or evaluation for an individual are required to file a referral form.

How to fill out referral form?

To fill out a referral form, one should provide the individual's personal information, details about the referral reason, relevant history, and any additional information that may assist the receiving professional.

What is the purpose of referral form?

The purpose of the referral form is to facilitate communication between professionals, ensure appropriate service delivery, and track the progress of the referred individual.

What information must be reported on referral form?

Information that must be reported includes the individual's name and contact details, the reason for referral, any pertinent medical or personal history, and the referring professional's information.