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].
If you are under the age of 18 or have a court appointed guardian please select the 'New Guardian' button and answer the questions regarding your guardian.
At least one contact method is required
Please read before responding. Long-Term Care providers are not doctors offices or primary care physicians. Long-Term Care services provide individual care on a regular and ongoing basis. This is often personal care or help with everyday activities or "activities of daily living." These include aid with bathing, dressing, grooming, eating, and movement.
When you are finished filling out the information please click the submit button to send your completed referral to DVR.