- To refer an individual, please complete this form and return it to Pennsylvania Independent Enrollment Broker (PA IEB) via fax or secure email.
- To initiate a secure email exchange, please email PAIEB@maximus.com to indicate you have a document containing Protected Health Information (PHI) or Personally Identifiable Information (PII) that you would like to send via email. PA IEB will return your email and initiate a secure email portal.
- If a document containing Protected Health Information (PHI) or Personally Identifiable Information (PII) is sent to PA IEB in a method that is not secure, then the document will not be opened.
- After the referral is received, the individual will be contacted via phone within 1-3 business days. PA IEB may use an automated dialer to make contact with these individuals. Please note that an application will not begin until the individual expresses to IEB staff interest in applying and the individual has Medical Assistance or completes and returns an application for financial eligibility for Long Term Services to PA IEB.
- . If “Referral Made By” section is completed by the Area Agency on Aging or by a LIFE provider, then the application is started. The applicant is not called to confirm interest in applying for waiver and / or LIFE program services.
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