Form 3671-J - Dental Services - Proposed Treatment Plan

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Texas Department of Aging
Form 3671-J
and Disability Services
June 2013-E
Dental Services – Proposed Treatment Plan
1. Applicant/Individual Name
2. Medicaid No.
3. Dental Evaluation Date
4. Applicant/Individual Address
5. Dentist Telephone No.
6. Dentist Address and Dentist Email Address
7. Proposed Date of Services
Description of Dental Services Needed and Medical Necessity for Services
A dental evaluation was completed on the above named individual. A description of the individual's dental problems and medical need for
dental services necessary to maintain or improve dental health of the individual is documented below. The attached treatment plan lists the
procedures and fees.
Does this plan require the services of an oral surgeon?
Name of Oral Surgeon Referral Made
Date of Referral:
Dentist ID
Signature – Dentist
Patient Statement and Signature – Guarantor's Signature
I certify agreement to the proposed dental treatment plan developed on the above evaluation date and allow the Home and Community
Support Services (HCSS) provider to arrange for the delivery of the proposed dental treatment services.
Signature – Individual or Representative
Signature – Guarantor/HCSS Provider


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