Dental Referral Form / Insurnace Verification
Community Type
Skilled Nursing Facility
Assisted Living Community
Memory Care Community
Personal Residence
Please Select Your Role In Submitting This Referral
*
Please Select
Patient
Power of Attorney (POA)
Staff at a Community or Facility
Health Plan Representative
Other
Referral Type
*
New Referral
Existing Patient
Person Making This Referral
Who Are You?
*
Patient
Power of Attorney
Community or Facility Staff
Insurances Staff
Other
Name
First Name
Last Name
Email
*
example@example.com
Referrer Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Referrer Title
*
Referrer Email
*
example@example.com
Patient Information
Patient Name
*
First Name
Last Name
Patient Email
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Where Does The Patient Need To Be Seen?
*
Personal Residence
Assisted Living or Memory Care Community
Skilled Nursing Facility
Group Home
Other
Facility/Community Name
*
Facility/Community City
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Payor Type
*
Private Pay
Medicaid
Medicare Advantage
Commercial Insurance
Other
Which Medicaid?
*
R13 (Full Vendor)
R14
Other
Who will pay for the dental services?
*
Facility
POA/Family
Applied Income Amount
*
Open DME?
*
Yes
No
Open DME End Date
*
-
Month
-
Day
Year
Date
Who handles the funds?
*
Facility
POA/Family
Financial status with facility?
*
Current
Not Current
Hospice?
*
Yes
No
Which Medicare Advantage Plan?
*
United Healthcare / Optum
Cigna
Provider Partners Health Plan PPHP
ProCare Advantage
Longevity
Humana
Aetna
Other
Reason for Referral
*
Routine dental care and evaluation
Broken/Loose/Decayed teeth
Weight loss
Broken/Loose/Lost dentures
Bleeding gums
Pain
Other
Can this patient make his/her own decisions?
*
Yes
No
Can this patient sign for themselves?
*
Yes
No
Upload Facesheet
*
Browse Files
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of
Client Profile
*
Browse Files
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of
Additional Documents
Browse Files
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of
Notes
Anything else we need to know about this patient?
Submit
Should be Empty: