Ndental referral form pdf

Please complete the information below so we can triage and most expeditiously provide care for your patient. Guaranty assurance company dina dental plan dina dental plan and 101 parklane blvd, ste 301 dina dental network sugar land, tx 77478 866 4363093 dina dental plan dentist referral form member prospect information member name member number address city state zip code dentist information name of dentist. The hiring of a referred employee must occur within six months of the initial referral date. Please fax to upmc for you epsdt department at fax number 4124547552. Referral form for use by community dentists when referring patients to childrens hospital colorado s dental center please email us the patients dental xrays. If you have questions or are having access problems, please call us toll free at 866 3462362. To track procedures, create this type of referral from the procedure info window see track referrals below. These are used when a client refers another person to the same services that he has been using. Communication to upmc for you fax form provider number. Good samaritan seniors clinic online referral form help. Just like a medicalsurgical referral, it specifies the reason for the referral and contains relevant clinical information, including lists of the patients medical problems, active. Referral forms adult referral forms are available below in pdf format.

Referral form for use by community dentists when referring. Click on the x button found on the top right of the form to close. California government and commercial provider manual. Refer a patient dental clinics, school of dentistry. Hospital dentistry clinic university of michigan u of m. Oral surgery student clinic referral form pdf 1959 ne pacific street, d251, box 3574 seattle, wa 9819574 phone.

General guidelines for referring dental patients revised june 2007 american dental association council on dental practice at the direction of the council on dental practice these general guidelines have been designed as a discussion about appropriate procedures for referrals and are intended to promote an improved patient referral process. Please complete the fields by typing in the appropriate information, using the tab key to move from field to field. Box 15609 speak with a representative sacramento, ca 95852 0609 to answer questions by phone. I understand that only those services which meet cigna dental care referral guidelines will be authorized for payment. Open your email client and attach the saved scanned document. Access dental plan referral department specialty care. Referral forms adult specialty referrals health care. The endodontics referral form can be printed, filled in by pen, and faxed or it can be filled in online and submitted as an email attachment.

Referral made dental referral fax form connect referral. When using a paper claim, be sure to attach the referral form to the top of the claim. Structuring referrals to dentistry safety net medical home. For more information, please contact the childrens program coordinator at 5032655627. General medical practitioner doctors name specialist name and title. Referrals issued after the service date will not be honored and the member will be responsible for the cost of all services. Please have your dentist or physician complete a referral form. A drab referral slip will likely find its way to the trash before your patients get the care they need. Pediatric dentistry clinic 801 south paulina street chicago, illinois 606127211 phone. When submitting electronically, include the referral form as an attachment. Liberty dental plan specialty care referral request p. Oral surgery referral is considered for individua l symptomatic or pathologically involved partial or full bony impactions, and difficult surgical or soft tissue extractions of pathologicsymptomatic teeth. I understand that the fees listed are based on current coverage. Dental referral form 111440 0177 019 2015 work street postal code other please explain below.

Good samaritan seniors clinic online referral form help to. The assigned dental office will also receive a copy of the referral letter. Access dental plan referral department po box 659005 sacramento, ca 958659005 telephone. When referring to a provider the ehr summaries of care is automatically sent. Liberty dental plan specialty care referral request. Make sure that you have the necessary attachments, such as radiographs, and, if this is an electronic form, that you. You can fill out the form below or complete the pdf here and send it via fax on 03 9514 6801.

Referral forms are an essential part of the process. This form must be completed by your current deltacare primary care dentist prior to seeking treatment from a specialist. Fill out and complete the good samaritan seniors clinic referral form then click on the disk icon to save the completed form. A structured referral is an order for a referral placed in the electronic health record ehr to a specific dentist. Scan the completed form and save as a jpeg or pdf file. When you have completed the form, please click on the submit navigation button at the bottom. Medical provider referral to dentist medical provider. Referral if referral given, name of dentist dental date if scheduled connect referral made dental referral fax form connect referral.

The referral bonus program has very few rules, however, these follow. Doctor referral bonus program gentle dental of new england. Reason for referral problem 0 uncooperative significant medical history please complete questionnaire on reverse side pediatric dentistry only treatment required identify. Liberty dental plan specialty eligibility verified. Referral forms for outside dentists faculty of dentistry. Submit a completed ada type claim form along with a copy of the specialty referral form indicating prescribed treatment and supporting diagnostic material to the appropriate aetna dental service center. Specialty r eferr al program nyu college of dentistry endodontics 7w implant dentistry 5w oral and maxillofacial surgery suite 201 oral mucosal lesions oral medicine 1a oralfacial pain tmd tmj 1a orthodontics 6w pediatric dentistry 9w periodontics 5w prosthodontics 4w. Please fax the completed referral form to 5033825342 or 8882297140. Indicate any special factors either dental or medical such as known allergies and specific medical problems relevant to diagnosis and treatment.

Specialty r eferr al program nyu college of dentistry endodontics 7w implant dentistry 5w oral and maxillofacial surgery suite 201 oral mucosal lesions oral medicine 1a oralfacial pain tmd tmj 1a orthodontics 6w pediatric dentistry 9w periodontics 5w prosthodontics. Just like a medicalsurgical referral, it specifies the reason for the referral and contains relevant clinical information, including lists of the patients medical problems, active medications, and medication allergies. Accessing referral forms referral forms are an essential part of the process. Certain procedures may require a patient payment in accordance with the applicable patient charge schedule for the group. Specialty r eferr al program nyu college of dentistry. Dcspecref 1110 deltacare specialty referral form deltacare member. Use our precompleted insurance form and simply complete the patientgp office portion of the insurance referral form, along with any other necessary information regarding your patients care.

You can save the information at any time and return with your email and. Please note we have a strict triage in place for requests for home visits. After submitting the form, you will receive a confirmation email stating the referral was received. Please ensure that you have read and understood the referral guidelines. Select when a patient is referred to another provider. A range of downloadable referral forms and related guidance documents are available below for practices, covering areas of dental specialty and location specific requirements. You will need to refer online unless you have approval from your local area team to use an alternate method. To fill in the endodontics referral form online you must be using free adobe acrobat reader as your pdf viewer. Provider forms and materials premier access insurance. Routine referral emergency referral gmc dhmocommercial managed care laphp. Oral surgery referral form american dental software. We would like to show you a description here but the site wont allow us. Reason for referral problem 0 uncooperative significant medical history please complete questionnaire on reverse side pediatric dentistry only treatment required identify teeth and treatment initial clinical examination.