Referrals

Monadnock Community Hospital Mobile Integrated Healthcare (MIH)

Patients referred to the MCH MIH program MUST have a primary care pare provider with MCH. To confirm the patient’s PCP is with MCH CLICK HERE

Department Referring(Required)

MCH Speciality Agency(Required)

MCH Inpatient Agency(Required)

EMS Agency(Required)

Home Healthcare Agency(Required)

Other (please specify department and or agency)(Required)

Name of person referring

First Last

Contact Information(Required)

Patient Information

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Date of Birth(Required)

Phone Number(Required)

PCP Name(Required)

First Last

Reason for Referral(Required)

Other reason for referral(Required)

Time/timeframe the MIH visit is requested(Required)

Please provide more details about the referral below.

If you are referring a patient for EMS use, please provide how many times you have been called to the home, how often the individual refuses transport, and how many times you transported them to an emergency department.

Please fax any provider orders, lab orders, discharge summaries, or other documents important for the MIH visit to our secure fax (603) 924-1709.

For urgent requests (under 48 business hours), please submit this form and call the MIH schedule/dispatch line 603-924-4699 ext. 2615

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