- DCH patient referral form (Script signed by PCP and must have ICD 10 codes)
- Patient must be referred by Primary Care Physician
- Insurance/Medicaid Card (Front & Back)
- Demographic Information
- Physician’s notes/diagnosis
- Please note: two or more complex Dx required for patient referral.
- Referral age is toddler to 12 years old.
- The only Medicaid insurance accepted are Driscoll Health Plan and TMHP Medicaid. All other private insurance is Out of Network.
- All services are only for short term.
For suspected but not yet diagnosed referral for Autism, please send screening results for Autism. Exp. - (MCHAT)
