Pennsylvania Area Health Education Center

Professional Development: Departments of Public Welfare and Health

Once you've completed the referral form below, your patient will be contacted by a PA Dept. of Labor and Industry, Office of Vocational Rehabilitation, Bureau of Blindness and Visual Services (BBVS) representative.

Requried fields are in bold.

Patient Information

Salutation
First Name MI
Last Name

Date of Birth: Month: Day: Year:
Citizenship Status
Gender

Address & Contact Information

Address 1
Address 2
City
State
Zip Code
County
Primary Phone
Email

Preferred Contact Method

Services Requested / Special Needs

Communication Needs
Visual Acuity: OD OS
Services Requested / Comments

Referral Information

Referring Office
Full Name of Office Contact
Phone Number

Verification

Funding for the Pennsylvania Area Health Education Center Program is provided by the Federal Department of Health and Human Services, Health Resources and Services Administration and the Pennsylvania Department of Health. The Commonwealth's Medical Community and Communities at Large provide additional support.