Dental Referral Portal

Dental Referral Form / Insurnace Verification
Community Type

Skilled Nursing FacilityAssisted Living CommunityMemory Care CommunityPersonal Residence
Please Select Your Role In Submitting This Referral*
Referral Type*

New ReferralExisting Patient
Person Making This Referral
Who Are You?*

PatientPower of AttorneyCommunity or Facility StaffInsurances StaffOther
Name

First NameLast Name
Email*
example@example.com
Referrer Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Referrer Title*
Referrer Email*
example@example.com
Patient Information
Patient Name*

First NameLast Name
Patient Email
example@example.com
Date of Birth*

MonthDayYear
Date
Where Does The Patient Need To Be Seen?*

Personal ResidenceAssisted Living or Memory Care CommunitySkilled Nursing FacilityGroup HomeOther
Facility/Community Name*
Facility/Community City*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Payor Type*

Private PayMedicaidMedicare AdvantageCommercial InsuranceOther
Which Medicaid?*

R13 (Full Vendor)R14Other
Who will pay for the dental services?*

FacilityPOA/Family
Applied Income Amount*
Open DME?*

YesNo
Open DME End Date*

MonthDayYear
Date
Who handles the funds?*

FacilityPOA/Family
Financial status with facility?*

CurrentNot Current
Hospice?*

YesNo
Which Medicare Advantage Plan?*

United Healthcare / OptumCignaProvider Partners Health Plan PPHPProCare AdvantageLongevityHumanaAetnaOther
Reason for Referral*

Routine dental care and evaluationBroken/Loose/Decayed teethWeight lossBroken/Loose/Lost denturesBleeding gumsPainOther
Can this patient make his/her own decisions?*

YesNo
Can this patient sign for themselves?*

YesNo
Upload Facesheet*

Browse Files

Cancelof
Client Profile*

Browse Files

Cancelof
Additional Documents

Browse Files

Cancelof
Notes
Anything else we need to know about this patient?
Should be Empty:

Person Making This Referral

Patient Information