DTS REFERRAL/APPLICATION

For those that have trouble completing the online form, please download the DTS Referral Application Revised Oct 2015 and mail or fax after completion. Mailing address and fax number on bottom of the form.



DTS Referral











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MaleFemale
MedicareMedicaidOther
MobilityVision
HearingCognitive
MentalOxygen Tank
Service AnimalNone


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YesNo
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