Specialty Care Referral Form PDF Details

Ensuring patients receive the specialized dental care they require involves a seamless referral process, underscored by the UDC Dental Specialty Care Referral Form for California residents. This form serves as a critical communication tool between general dentists and dental specialists, ensuring the transfer of essential patient information, such as personal details, insurance coverage, and the specific nature of the required specialty care. Included are pertinent details like patient name, contact information, dentist and specialist details, and comprehensive dental records such as periodontic conditions, endodontics, oral surgery, and pedodontics needs, alongside any enclosed items like X-rays or periocharts. The form also addresses the patient's compliance with past procedures and their overall prognosis, providing a thorough understanding of the patient's dental history and needs. Specifically designed for the UDC Dental network in California, this form highlights the necessity of a tailored approach to specialty dental referrals, ensuring that all involved parties are well-informed, thereby facilitating efficient and effective patient care. With spaces dedicated to authorization, emergency status, and comments from the UDC Dental Director, it underscores the form's role in maintaining high standards of care and adherence to policies, reinforcing the shared goal of achieving optimal patient outcomes.

QuestionAnswer
Form NameSpecialty Care Referral Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesspecilaty referral dental form for assurant, UDC, X-rays, ADA

Form Preview Example

UDC Dental

Specialty Care Referral Form

 

 

 

 

California, Inc.

All pertinent specialty care information must be provided

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

Patient name

 

 

Daytime phone # (

)

 

 

 

FIRST

MIDDLE

LAST

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

STREET

 

CITY

STATE

 

 

 

ZIP CODE

Subscriber

 

 

FIRST

MIDDLE

LAST

Plan #

 

Group #

 

Referring Dentist

 

 

 

Participating Specialist

 

 

Address

 

 

Subscriber I.D. #

Patient D.O.B.

Dentist I.D.

#

 

 

 

Phone #

(

 

 

)

 

 

STREET

 

 

 

 

 

CITY

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Periodontics

Required Enclosed Items:

Periocharting

 

 

F.M. X-rays

 

 

Perio Case Type

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates of Scaling & Root Plaining

 

 

,

 

 

 

,

 

 

,

 

 

 

 

 

 

 

Compliance with home care instruction:

Good

Fair

 

 

 

Poor

 

 

Prognosis of Case:

Good

Fair

 

Poor

 

 

 

 

 

 

 

 

 

 

 

 

 

Service Requested:

Eval

Surgery

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Endodontics

Required P.A. X-rays enclosed?

Yes

No

 

** 3310 Anterior - Tooth #

 

 

 

 

 

 

 

Calcified Canals

 

 

 

 

 

 

 

 

 

 

** 3320 Bicuspid - Tooth #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Retreatment

 

 

 

 

 

 

 

 

 

 

** 3330 Molar - Tooth #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Complications

 

 

 

 

 

 

 

 

 

 

** 3410 Apico - Tooth #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oral Surgery

 

Required Panoramic X-rays enclosed?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

** 7210 Surgical Extraction - Tooth #

 

 

 

 

 

** 7230 Partial Bony Impaction - Tooth #

 

 

 

 

 

 

 

 

** 7220 Soft Tissue Impaction - Tooth #

 

 

 

 

 

** 7240 Full Bony Impaction - Tooth #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pedodontics

 

Required Bitewing and Periapical X-rays enclosed?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Age of Child:

 

 

 

 

 

 

years

Patient compliance to treatment?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Orthodontics

 

Age of Patient:

 

 

 

 

years

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please list complications prohibiting Family Dentist from performing the procedures requested:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Services Requested

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tooth

 

ADA Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Approved

 

 

Denied

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UDC DENTAL CALIFORNIA, INC. USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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UDC Dental Director

 

 

 

 

 

 

 

Date Received

 

 

Date to Specialist

UDC Signature

 

 

 

 

 

 

Date

 

 

Contract Compliance

 

Yes No

Member Eligibility

Yes No

Emergency Yes

No

X-Ray Yes

No Retro Review

 

 

UDC Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Send to: UDC Dental California, Inc. 6310 Greenwich Drive, Suite 210, San Diego, CA 92122 Toll Free Phone # 1.800.821.1294

THIS REFERRAL IS ONLY VALID FOR 60 DAYS FROM THE DATE SENT TO THE SPECIALIST INDICATED ABOVE

SCRF-CA 05/98

**Current Dental Terminology © American Dental Association

KC4531CA (10/2009)

 

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How to fill out assurant dental referral form stage 1

2. Right after performing this section, head on to the subsequent stage and enter the essential details in all these fields - Retreatment, Other Complications, Molar Tooth, Apico Tooth, Oral Surgery, Required Panoramic Xrays enclosed, Yes, Surgical Extraction Tooth, Partial Bony Impaction Tooth, Soft Tissue Impaction Tooth, Full Bony Impaction Tooth, Pedodontics, Required Bitewing and Periapical, Yes, and Age of Child.

A way to complete assurant dental referral form portion 2

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