Assurant Dental Specialty Referral Form Printable Information about the specialist or consulting dentist s fee for the consultation or evaluation instructions that will make the patient s introduction to the specialist or consulting dentist a smoother transition This could include preoperative instructions educational pamphlets or even a map with directions
REASON FOR REFERRAL Consultation Treatment Please provide specialist with appropriate details of problem i e urgency areas of concern RELEVANT HISTORY Indicate any special factors either dental or medical such as known allergies and specific medical problems relevant to diagnosis and treatment Quick steps to complete and e sign Assurant specialty referral form online Use Get Form or simply click on the template preview to open it in the editor Start completing the fillable fields and carefully type in required information Use the Cross or Check marks in the top toolbar to select your answers in the list boxes
Assurant Dental Specialty Referral Form Printable
Assurant Dental Specialty Referral Form Printable
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Printable Dental Referral Form Template Printable Templates
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Printable Dental Referral Forms
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Specialty Referral Form CA Patient Signature I have reviewed the following treatment plan I authorize release of any information relating to this referral I understand th at I am responsible for deductible charges copayments and all costs for services not covered by my Dental Health Services plan Specialty Referral Request Form o Pre Authorization o Direct o Self o Emergency Referring Provider Name Phone Number Employee Name ID Street Address Street Address City State and ZIP Code City State and ZIP Code Home Phone Pacific Union Dental Direct Compensation AARP Medicare Complete Secure Horizons PacifiCare 1 888 877 7828
Specialist Services requested Reason for referral This section must be completed for Prophylaxis date s Root planing scaling indicate quadrant and date s periodontal referrals Root planing or perio maintenance follow up date s SECTION 3 APPOINTMENT INFORMATION TO BE COMPLETED BY SPECIALIST Tooth Surface Procedures Performed How to use Carepatron s free Dental Referral Form Template Our free Dental Referral Form is easy to use and fully digital Here s how to get started Step 1 Access the template Download the referral form using this page s link or the Carepatron app You can also get a copy from our resources library Step 2 Use the digital format or print a
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P O Box 254888 Sacramento CA 95865 4888 Primary Care Dentist PCD Referral must be made to a network specialist If there is no network specialist available you must obtain prior authorization from the Plan All referrals must be made in compliance with Plan Referral Guidelines Care coordination services are offered by the Telephone Service Center TSC Care coordination services allow Medi Cal members to call and gain access to dental services with the direction and support of our TSC agents who assist members with Members can access care coordination services by calling the TSC at 800 322 6384
Cigna Dental Specialty Referral Form REFERRAL TYPE Check one REFERRAL DATE EN OS PE PD CONTRACT HOLDER SPECIALTY DISCOUNT PLAN PT CHG SCH See Footnote Yes No ALTERNATIVE PARTICIPANT IDENTIFIER AMI PATIENT S BIRTH DATE REFERRING DR DENTAL OFF SPECIALIST NAME PATIENT RELATIONSHIP Self Spouse Dependent Care Coordination Care coordination services are offered by the Telephone Service Center TSC Care coordination services allow Medi Cal members to call and gain access to dental services with the direction and support of our TSC agents who assist members with Members can access care coordination services by calling the TSC at 800 322 6384
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Specialty Dental Patient Referrals Westside Endodontics
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https://www.ada.org/resources/practice/practice-management/specialty-referrals
Information about the specialist or consulting dentist s fee for the consultation or evaluation instructions that will make the patient s introduction to the specialist or consulting dentist a smoother transition This could include preoperative instructions educational pamphlets or even a map with directions
https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/publications/guidelines-for-practice-success/mngpatients_referral_to_specialist.pdf?rev=e21a857be9d643af8727e388aa549f68&hash=DF3F57EB5DDD7322A03DF4C6436744FB
REASON FOR REFERRAL Consultation Treatment Please provide specialist with appropriate details of problem i e urgency areas of concern RELEVANT HISTORY Indicate any special factors either dental or medical such as known allergies and specific medical problems relevant to diagnosis and treatment
Specialty Dental Patient Referrals Friendly Dental Specialty Center
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Assurant Dental Specialty Referral Form Printable - Specialty Referral Form CA Patient Signature I have reviewed the following treatment plan I authorize release of any information relating to this referral I understand th at I am responsible for deductible charges copayments and all costs for services not covered by my Dental Health Services plan
