Deltacare Usa Form PDF Details

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Form NameDeltacare Usa Form
Form Length1 pages
Fillable fields59
Avg. time to fill out12 min 7 sec
Other namesdelta dental referral, delta care referral, deltacare usa specialty care referral form, deltacare referral form

Form Preview Example

Specialty Care Referral Form







Customer Service

Patient: Please give this form to the specialist at the time of the appointment.



















Referral type: (Check one)

Referral number:__________________________


c Endodontist

c Oral Surgeon

c Periodontist

c Pediatric Dentist

c Orthodontist








Payments are subject to enrollee’s plan beneits and eligibility veriiciation.


Primary Enrollee: c Yes c No

c Self

c Spouse

c Dependent

Last Name:__________________________

First Name: _________________

Middle Initial _______ Date of Birth:________









Primary Enrollee Last Name: _______________________________________

First Name: ________________________________

Address: ________________________________________________________

City: ______________________________________

State: _________ Zip: ________________________ Group/Plan #: _________________________ ID#: ______________________

Daytime Phone #: _____________________________________ Work Phone #: __________________________________________

Does Patient have another Dental coverage? c Yes

c No

Other Dental Carrier Name: _______________________________

Policy Holder Name: ___________________________________

Policy Holder ID: _______________________________________













Contracted Specialist Not Available:

c Yes

c No

X-Rays Sent with Referral? c Yes c No

Referring Facility Name: ___________________________________________ Fac. #: _____________ Fac. Phone #: _____________

Specialist Name: ____________________________ Specialist #: _____________ Specialist Phone #: ____________________

Address: ____________________________________________________ City: ___________________________________________

State: _________ Zip: ____________ Reason for referral: ___________________________________________________________

Comments: ___________________________________________________________________________________________________

Procedure #


Tooth #

Patient Copayment

















This specialty care referral is only for those procedures listed above. The general dentist has determined these procedures to be beyond his/her scope. All

claims will be subject to DeltaCare USA’s Dental Consultant review. Please refer to section ive of the Dentist Handbook for referral guidelines and general

dentist responsibility. Any additional procedure(s) deemed necessary by the specialist must be pre-authorized in writing or have general dentist approval.


Signature of Patient


Signature of Referring Dentist


This form must be attached to the claim form when submitting for payment.


Administrator — DeltaCare USA


Claims Department


P.O. Box 1810, Alpharetta, GA 30023

For a list of DeltaCare USA underwriting companies and plan administrators, please consult your dentist handbook or visit


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In the Contracted Specialist Not, X, Rays Sent with Referral, Referring Facility Name: Fac, Specialist Name: Specialist #: , Address: City: , State: Zip: Reason for referral: , Comments: , Procedure #, Description, Tooth #, Patient Co, payment This specialty care referral is, Signature of Patient, Date, and Signature of Referring Dentist box, jot down your details.

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