Form 3671-J - Dental Services - Proposed Treatment Plan
Download a blank fillable Form 3671-J - Dental Services - Proposed Treatment Plan in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 3671-J - Dental Services - Proposed Treatment Plan with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Texas 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?
Yes
No
Name of Oral Surgeon Referral Made
Date of Referral:
Dentist ID
Date
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
Date
Signature – Guarantor/HCSS Provider
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical