Dental Referral Form / Insurance 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 Submitting This Form
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
Referrer Phone#
*
-
Area Code
Phone Number
Referrer Title
*
Referrer Email
*
example@example.com
Power of Attorney Information
POA Name
First Name
Last Name
POA Phone#
-
Area Code
Phone Number
POA Email
example@example.com
Patient Information
Patient Name
*
First Name
Last Name
Patient Email
example@example.com
Patient Phone#
-
Area Code
Phone Number
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
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
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?
*
Aetna
Cigna
Health Plan of San Mateo
Humana
Longevity
Partners Health Plan
ProCare Advantage
Provider Partners Health Plan (PPHP)
Texas Independence Health Plan
United Healthcare / Optum
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
Cancel
of
Client Profile
*
Browse Files
Cancel
of
Additional Documents
Browse Files
Cancel
of
Notes
Anything else we need to know about this patient?
Submit
Should be Empty: