Dental care is an important part of overall health, and it's important to have a regular dental check-up. If you need to see a dentist but don't have one, your doctor can provide you with a referral. Dentists are specialists in oral health and can provide preventive care, diagnose and treat problems, and perform surgeries. When choosing a dentist, it's important to find one who is qualified and has experience with the type of dental work you need. You can also ask your friends or family for referrals. The bottom line is that having a regular dental check-up is essential for keeping your teeth healthy!
| Question | Answer |
|---|---|
| Form Name | Dental Consultation Referral Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | maryland uniform consultation form, uniform dental referral, md uniform consultation referral, md dental referral |
Maryland Uniform Dental Consultation Referral Form
Date of Referral:
Patient Information:
Name: (Last, First, MI)
Date of Birth (MM/DD/YY): Phone:
Member #:
Site #:
Carrier Information:
Name:
Address:
Phone Number: |
( |
) |
Facsimile/Data #: |
( |
) |
Primary or Requesting Dentist
|
Name (Last, First, MI): |
|
|
Specialty: |
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
Institution/Group Name: |
Provider ID #: 1 |
Provider ID #: 2 (If Required) |
||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Address: (Street #, City, State, Zip) |
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Phone Number: ( |
) |
|
|
Facsimile/Data #: ( |
) |
|
|
|||||
|
|
|
|
|
Specialist Dentist |
|
|
|
|
||||
|
Name: (Last, First, MI) |
|
|
Specialty: |
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|||
|
Dental Office Name: |
|
Dental Office Code: |
Provider ID/License #: |
|||||||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Address: (Street #, City, State, Zip) |
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Phone Number: ( |
) |
|
|
Facsimile/Data #: ( |
) |
|
|
|||||
|
|
|
|
Referral Information |
|
|
|
|
|||||
|
Reason for Referral: |
|
|
|
|
|
|
|
|
|
|
|
|
|
Brief History, Diagnosis, and Test Results: |
|
|
|
|
||||||||
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
||||||
|
Services Desired: Provide Care as Indicated: |
|
|
|
Teeth Diagram: Indicate Missing Teeth with an "X". |
||||||||
[ |
] Initial Consultation Only |
|
|
|
|
|
|
|
|
|
|
||
[ |
] Consultation with Specific Procedures (Specify) |
|
|
|
|
|
|
||||||
[ |
] Other: (Explain) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Place of Service: |
|
|
|
|
|
|
|
|
|
|
|
|
[ |
] Office |
|
|
|
|
|
|
|
|
|
|
|
|
[ |
] Hospital |
|
|
|
|
|
|
|
|
|
|
|
|
[ |
] Other: (Explain) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Authorization # (If Required): |
|
|
|
|
Referral is Valid Until: (Date) |
|||||||
|
|
|
|
|
|
|
|
(See Carrier Instructions) |
|||||
|
Signature: (Individual Completing This Form) |
|
|
|
Authorizing Signature: (If Required) |
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Referral certification is not a guarantee of payment. Payment of benefits is subject to a member’s eligibility on the date that the service is rendered and to any other contractual provisions of the plan/carrier.
White: Carrier; Yellow: Primary or Requesting Provider; Pink: Consultant/Facility Provider; Goldenrod: Patient
See Reverse and Carrier/Plan Manual for Specific Instructions
There are no special instructions in completing this form.