Refer a Patient - Community Health Systems, Inc.

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Holiday Notice: All CHSI locations will be closed on February 16th, in observance of President's Day.
We will reopen on Tuesday, February 17th, with normal business hours.

Lets Connect You To Care!

You will be contacted within 2-business days.

This is only for non-emergency related services. If you are experiencing any physical or mental health emergency, please dial 9-1-1 or head to the nearest hospital

If you are referring a patient from a health care practice, please do not submit this form and instead contact the desired clinic directly.

We apologize for any inconvenience. Our system is currently down, please check in at a later time for an update.

Are you referring from a providers office or health care practice? *

Yes
No

Please contact the desired health center's referral department directly.
Click here to access our locations page

Name *

Patient or Parent/Guardian

Phone Number *

Email

If available

Is this a school-based referral? *

Yes
No

Is this referral coming from a school site or school district?

Is this referral for confidential services, requested by student? *

Yes
No

Do you have verbal or written consent from Parent/Guardian to initiate this referral? *

Yes
No

Parent/Guardian verbal or written consent is required to initiate school-based referrals to any service.

Do you have verbal or written consent from the student to initiate this referral? *

Yes
No

Verbal or written consent by the student is required to initiate school-based referrals to any service.

We apologize for any inconvenience, verbal or written consent from parent/guardian, to the school, is required before school officials may initiate this new patient referral of a student or their family.

Services Needed *

Adult Medical
Pediatric Services
Women's Health
Prenatal Care
Dental Care
Behavioral Health
Chiropractic Care
Vision Care
Health Education
Insurance Enrollment
Teen Wellness Clinic*

*Teen Wellness offers confidential family planning & contraceptive counseling, free for those who qualify (Ages: 12+)

Select Location *

Organization Referring

Only if applicable

Name of School Referring *

Only if applicable

Contact Information of School Official Referring *

Please provide your full name, email, and phone number

Notes

Please do not include any personally identifiable information in this section (i.e. DOB, Social Security Number, Medical Record Number or Insurance Information)

Phone

Name

Phone Number

Email

Services

Adult Medical Pediatrics Women's Health Prenatal Care Dental Care Behavioral Health Vision Care Health Education Insurance Enrollment Teen Clinic*

*Confidential Family Planning & Contraceptive Counseling

Location

Organization Referring

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