Care Inquiry
Submit a new procedure 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.
By submitting this form, you acknowledge your responsibility to protect patient confidentiality in accordance with HIPAA regulations.
Submit a request for a specific procedure or treatment that has been identified for a patient.
Inquire about capabilities and whether a potential procedure for a patient can be accommodated.