Certification Of No Medical Contraindication printable pdf download

Certification Of No Medical Contraindication

Date/Fecha

Eligibility Specialist/Especialista de elegibilidad

(Name and Address of Client's Attending Practitioner)

Office Address and Telephone No./Oficina y teléfono

Certification of No Medical Contraindication — Dental / Certificación de que no hay contraindicación médica — Dental

Name of Patient

Client No.

Facility Name and Address

To the patient's attending practitioner:

When determining the amount that the patient must pay for his care in a nursing facility, this department allows a deduction

from the patient's income for the cost of routine dental services. Your certification that these services

List Dental Services:

are not medically contraindicated for the patient is required before the department can allow this deduction.

Please complete this form and return it in the postage-paid envelope. (The department cannot pay you for

completing this form.)

To be Completed by Attending Practitioner

As the above-named patient's attending practitioner, I certify that the following dental service(s) required

is/are not medically contraindicated for the patient.

Signature-Practitioner

Date

Name of Practitioner (please type or print)

Type of Practice *

Telephone No. (include AC)

Address

MD, DO, nurse practitioner, clinical nurse specialist or physician assistant

Dental Treatment Plan:

Approved

Disapproved

Signature-DADS Regional Nurse

Date

Form H1263-B / 10-2007

Certification Of No Medical Contraindication