Care Request

Submit a new care request for review by DCA administrators

IMPORTANT: Privacy and Security Notice

This is a public-facing form that does not require login credentials. To protect patient privacy and maintain HIPAA compliance:

• DO NOT include any protected health information (PHI) in your responses
• DO NOT include patient names, dates of birth, medical record numbers, or any other identifying information
• When describing the procedure, provide only the general type and nature of the procedure—do not include specific patient details, diagnoses, or medical history
• Only provide the information specifically requested in this form. Any patient-specific details should be communicated through secure, HIPAA-compliant channels.

I understand and acknowledge my responsibility to protect patient confidentiality in accordance with HIPAA regulations.

Organization Name *

Requester Name *

Phone *

Email *

Request Type *

Case Submission

Submit a request for a specific procedure or treatment that has been identified for a patient.

Care Inquiry

Inquire about capabilities and whether a potential procedure for a patient can be accommodated.

High Priority

If you are experiencing a serious or life-threatening medical emergency, please call 911.