Deltacare Usa Form PDF Details

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QuestionAnswer
Form NameDeltacare Usa Form
Form Length1 pages
Fillable?Yes
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.

 

800-422-4234

 

 

 

 

 

 

REFERRAL INFORMATION

 

 

 

 

 

 

 

 

 

Referral type: (Check one)

Referral number:__________________________

Date:__________________

c Endodontist

c Oral Surgeon

c Periodontist

c Pediatric Dentist

c Orthodontist

 

 

 

 

 

 

 

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

PATIENT INFORMATION

Primary Enrollee: c Yes c No

c Self

c Spouse

c Dependent

Last Name:__________________________

First Name: _________________

Middle Initial _______ Date of Birth:________

 

 

 

 

PRIMARY ENROLLEE INFORMATION

 

 

 

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: _______________________________________

 

 

 

 

REFERRING FACILITY INFORMATION

 

 

 

 

 

 

 

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 #

Description

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

Date

Signature of Referring Dentist

Date

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

SEND CLAIM TO:

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 www.deltadentalins.com

FRM_0028_01.20.2011

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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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