Referrals Submit A Referral Please enable JavaScript in your browser to complete this form.Patient Full Name *Patient Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeProvider / Referrer Email *Patient Phone Number *Provider / Referrer Full Name *Provider / Referrer Phone Number *Patient Email *Comments / MessageSend Message Referral Contact Info Corporate Office 4934 South Laurel Road London, KY 40744 (606) 864-0724 Telephone (800) 225-4110 Call Toll-Free (606) 864-5520 Fax referrals@phhca.com