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Patient Referral Form

Patient Referral Form

To refer a patient, download and fill out the form below. Follow the instructions included on the form for how to send the referral.

New Patient Referral Form


DCH Health System accepts all forms of valid insurance coverage, and we will coordinate with your physician or referring facility to gain all necessary pre-certification and/or authorization. However, not all insurance policies are considered in-network. This is especially true regarding out of state insurance policies. In this event, a higher patient out-of-pocket payment will likely occur. If you have any questions, please call your insurance company for in and out of network benefits.