Referral for Services

This form is voluntary. Please answer all the questions included on the referral. While all the items are not required to submit a referral, DVR does need this information. Not providing some of the information could delay the processing of your referral. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. Provision of your Social Security Number (SSN) is voluntary; not providing it could result in an information processing delay.

Required fields within each tab are marked with an asterisk*. To change tabs either click the tab heading or the Next Tab/Previous Tab links at the bottom of the Referral.

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DVR-17445-E (07/2020)