Authorization For Dental Services

Authorization For Dental Services

Michigan Geriatric Dental Care - Dr. Mary M. Fisher - Office: (248)932-9243
In an effort to provide comprehensive health care to our residents, we have contracted with Michigan Geriatric Dental Care to perform medically necessary dental care. The treating dentist will provide dental examinations as ordered by the attending physician.The treating dentist will bill the resident's dental insurance when appropriate and the responsible party when necessary. Other than an examination, the dentist will contact the resident and/or responsible party for approval of dental treatment and payment prior to any dental work being completed.
Select one of the following:

I wish to use the services of the Facility's contracted dentist as ordered by my attending Physician.I do not wish to use the services of a dentist.
In the event that treatment is required by the dental professional noted above, the dentist should contact the individual (named) below to discuss care and treatment:

Powered by Jotform SignClear
PRINTED NAME OF RESIDENT AND/OR RESPONSIBLE PARTY:

First NameLast Name
Today's Date:

MonthDayYear
Date
Should be Empty: