Deltacare Usa Form – Fill Out and Use This PDF

Updated: Oct 29, 2026

The DeltaCare USA form is a Specialty Care Referral Form designed to facilitate the referral process for patients requiring specialized dental care. It captures essential information such as referral type, patient and primary enrollee details, and specifics about the referring facility and specialist. The form also outlines the procedures authorized, emphasizing that payments depend on the enrollee's plan benefits and the verification of eligibility. For those in need of specialized dental care, completing and submitting this form is a critical step. Click the button below to fill out the form.

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Deltacare Usa Form PDF Details

Navigating the intricacies of dental care, especially when it involves specialized treatment, can often be daunting for patients. The DeltaCare USA Specialty Care Referral Form plays a crucial role in streamlining this process by functioning as a vital communication tool between primary dental care providers, specialists, and patients. This form is designed to ensure that when a general dentist identifies the need for specialized dental care that goes beyond their capacity—whether it be endodontic, oral surgery, periodontics, pediatric dentistry, or orthodontics—they can effectively refer their patient to the appropriate specialist. The referral form includes comprehensive sections for capturing patient information, specifying the type of referral, and detailing the primary enrollee’s data, including their insurance coverage and contact information. Furthermore, it outlines the referring facility's details, the specialist's information, and the reasons behind the referral, emphasizing the need for pre-authorization for any additional procedures not initially listed. This form not only facilitates a smoother transition to specialty care but also underscores the importance of verifying the patient's eligibility and benefits under their specific dental plan. By ensuring that all necessary information is attached for claim submissions, the form aids in maintaining transparency and efficiency in the payment process, marking a significant step towards optimized patient care and administrative handling.

Question	Answer
Form Name	Deltacare Usa Form
Form Length	1 page
Fillable?	Yes
Fillable fields	113
Avg. time to fill out	15 sec
Other names	deltacare usa direct referral form, deltacare usa referral, deltacare specialty referral form, deltacare usa specialty referral

How to Fill Out DeltaCare USA Specialty Care Direct Referral Form (FRM_0027)

DeltaCare USA Specialty Care Direct Referral Form (FRM_0027) at a glance

What it is: The DeltaCare USA Specialty Care Direct Referral Form: information for the referring dentist and specialist.

Who signs: Referring Dentist Signature and Date. Preauthorizing Specialist Signature and Date. Specialist Signature for Payment and Date.

A filled-in DeltaCare USA Specialty Care Direct Referral Form (FRM_0027) example: a dentist refers a child to a periodontist

DeltaCare USA Specialty Care Direct Referral Form (FRM_0027) example filled out, example: a dentist refers a child to a periodontist — Alex Sample, a referring dentist, completes the DeltaCare USA Direct Referral Form. Sam Sample, a subscriber's child, needs one procedure from a contracted periodontist by direct referral. The picture shows the whole form; its names and figures are sample values. Sam is the child of the subscriber Lee A. Sample, who works for Example Co., so Self, Spouse and Other stay empty under Patient Relationship to Primary Enrollee/Subscriber. Sam has no other dental plan, so Name and Address of Other Dental Plan, Other Dental Plan Group # and Amount Paid by Other Dental Plan stay empty. The treatment is periodontal, so Endodontist, Oral Surgeon and Orthodontist stay empty under Needed Specialist Type, and Non-Contracted stays empty under Specialist Plan Status because the specialist is contracted. The referral is direct and not an emergency, so both Preauthorized Referral boxes under Referral Type stay empty and nothing goes in DeltaCare USA Emergency Authorization Number. Two radiographs go to the specialist, so to DeltaCare USA, Full-mouth periodontal charting and Other under Radiograph(s) Forwarded with This Form stay empty. Comments is left blank because there is nothing to add, Surfaces is left blank because the procedure covers a quadrant, and the Procedure rows 2 to 8 stay empty because there is one procedure. Date of Service and Specialist Fee are left blank because they are reserved for the specialist, and Total Fee and Patient Pays stay empty because treatment has not happened. Nothing goes in Preauthorizing Specialist Signature because the referral is not preauthorized, and nothing goes in Specialist Signature for Payment because treatment is not completed. Alex signs and dates the form on March 14, 2026.

How to fill out DeltaCare USA Specialty Care Direct Referral Form (FRM_0027), box by box

Information for the referring dentist and specialist

See the Dentist Handbook to verify enrollee benefits and that referral criteria have been met. For Direct Referral to a network specialist, complete the form and attach needed radiographs and charting. Send to the specialist either directly or by giving to the enrollee for the specialist. Note: This form is not required for referral to a contracted pediatric dentist. If unsure whether a network specialist is available, phone Customer Service department at 866-774-5595. For emergency specialty care, Customer Service can issue an Emergency Authorization Number over the telephone. If there is no local network specialist, and the enrollee needs non-emergency specialty care, mail this form and required radiographs/charting to Delta Dental. DeltaCare USA, Claims Department, P.O. Box 1810, Alpharetta, GA 30023.

Patient Name, Relationship and Date of Birth

Enter the Patient Name (First) (Middle) (Last) and check the Patient Relationship to Primary Enrollee/Subscriber: Self, Spouse, Child or Other.

Enter the Patient Date of Birth as Month / Day / Year.

Patient Covered by Any Other Dental Plan?

Check Yes or No for Patient Covered by Any Other Dental Plan?, then enter the Name and Address of Other Dental Plan, the Other Dental Plan Group # (Group Number) and the Amount Paid by Other Dental Plan.

Subscriber/PE

For the Subscriber/PE, enter the ID #, Name (First) (Middle) (Last), Daytime Telephone Number(s), Street Mailing Address, City, State Zip, Employer or Group Name and Group/DeltaCare USA Plan Number.

Referring Contract General Dentist or Pediatric Dentist

For the Referring Contract General Dentist or Pediatric Dentist, enter the DeltaCare USA Facility Number, Facility Name, Facility Street Address, Facility City, State ZIP and Facility Telephone.

Specialist Receiving Referral

For the Specialist Receiving Referral, enter the DeltaCare USA Facility Number (Or Enter “Non-Contracted”), Specialist Name, Specialist Street Address, Specialist City, State ZIP and Specialist Telephone.

Needed Specialist Type

Needed Specialist Type (check one): Endodontist, Oral Surgeon, Orthodontist or Periodontist.

Specialist Plan Status

Specialist Plan Status (check one): DeltaCare USA Contracted or Non-Contracted.

Referral Type

Referral Type (check one): Direct Referral to a DeltaCare USA network specialist, Preauthorized Referral for Routine Specialty Services(s) or Preauthorized Referral for Emergency Specialty Services(s).

Enter the DeltaCare USA Emergency Authorization Number with the Preauthorized Referral for Emergency Specialty Services(s).

Radiograph(s) Forwarded with This Form

For Radiograph(s) Forwarded with This Form, check Radiographs and enter How many?, check Full-mouth periodontal charting, or check Other, and check to DeltaCare USA or to Specialist.

Comments and Procedure Description

Enter Comments, then for each procedure enter the Procedure Number, Procedure Description, Tooth No., Quadrant, Arch, Surfaces and Enrollee's Copayment.

Date of Service and Specialist Fee are [RESERVED FOR SPECIALIST].

Total Fee and Patient Pays

Enter the Total Fee and Patient Pays.

Referring Dentist Signature

Referring Dentist Signature: In my professional judgment all services I have listed are needed and beyond the scope of a general or pediatric dentist. The information supplied herein is true and accurate.

Preauthorizing Specialist Signature

Preauthorizing Specialist Signature: The treatment listed is necessary in my professional judgment and I request a predetermination of cost and authorization. Signature and Date.

Specialist Signature for Payment

Specialist Signature for Payment: The treatment listed was completed on the date(s) of service listed. All information I have provided concerning this case is true and accurate. Signature and Date.

More rules for DeltaCare USA Specialty Care Direct Referral Form (FRM_0027)

Note, all dental services listed may not be covered under all DeltaCare USA plans and referrals are subject to an enrollee's eligibility and plan‑specific benefits, limitations and exclusions. For further information, enrollees can refer to their Evidence of Coverage.

Sources

[1] FRM_0027 (rev. 08/24), DeltaCare USA Specialty Care Direct Referral Form, Delta Dental (the Official source link on this page).