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Submit a Referral

Primary Tasks

    Secondary Tasks


      All information you provide is secure and confidential. There are multiple ways you can submit a referral:

      • Online
      • U.S. Mail – fill out the PDF form on paper or online, print and mail it to:
        Iowa Department for the Blind
        524 Fourth Street
        Des Moines, IA 50309-2364
      • Fax – fill out the PDF form on paper or online, print and fax it to:
        Fax: 515-281-1263
      • E-mail – fill out the PDF form online, save it, and attach it in e-mail to:
        put “REFERRAL” in the e-mail subject line
      • Phone in a referral to:
        Local Phone: 515-281-1333; Toll free (in Iowa): 800-362-2587

        Referral Form

        Personal Information

        Additional Information (optional)

        Format: 10/23/2008
        Acuity with Correction
        Format: 10/23/2008.
        For example; Alone, With Spouse, Etc.
        Employment Status of Referral
        If you have been employed in the past but are not employed now, enter the date or year of when you were last employed.
        Interested In

        Referral Source

        If you are completing this form to refer someone other than yourself:

        Format: 10/23/2008.

        Other Information

        By submitting this form, you accept the Mollom privacy policy.