Request For Dental Exemption From Plan Enrollment Form

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REQUEST FOR DENTAL EXEMPTION FROM PLAN ENROLLMENT
Dear Medi-Cal Dental Provider:
Re (Name of Medi-Cal Beneficiary): _______________________________________________________
Beneficiary’s Benefits Identification Card Number (BIC): __________________________________________________________
Beneficiary’s Client Index Number (CIN): _________________________________________________________________
Most Medi-Cal beneficiaries in Sacramento County are required to join a Dental Managed Care Plan. As
an alternative to joining a Medi-Cal Dental Managed Care Plan, however, beneficiaries who are receiving
treatment for a complex medical (dental) condition under the supervision of a dentist who is a Medi-Cal
dental provider, but is not affiliated with any of the Medi-Cal Dental Managed Care Plans, may request to
continue to see their dentist on a Regular Medi-Cal Dental (Fee-For-Service) basis through the duration of
the treatment plan.
The Medi-Cal beneficiary listed above indicated that you are currently providing his/her dental care for a
complex medical (dental) condition. The beneficiary has requested to continue to receive care from you,
but may only do so with certain verification from you. If you believe that potentially deleterious results to
the patient’s health would occur, or access to necessary medical (dental) services would be impeded if
the patient’s continuity of care were to be disrupted by a change in dentists at this time, please
complete and return this form to the Department of Health Care Services’ Health Care Options enrollment
broker contractor at the address below.
Please attach additional pages, as needed, to fully explain the patient’s dental treatment plan and all
complicating factors. If treatment has been authorized by the Medi-Cal Dental (Denti-Cal) program,
attach copies of outstanding Notices of Authorization(s).
Patient Information
What is the patient’s dental diagnosis? ______________________________________
What is the patient’s current/proposed treatment plan? __________________________
What is the estimated duration of treatment plan (in months)? ____________________
What is the estimated completion date? ______________________________________
Explain why this treatment plan cannot be completed by a dental managed care plan (attach additional
pages, if needed): _________________________________________
______________________________________________________________________
______________________________________________________________________
Dentist Information
Are you on the provider network of any Medi-Cal Dental Managed Care Plan?
No
Yes
If yes, specify all plans in which you participate: ______________________________
______________________________________________________________________
Dental License Number: __________________________________________________
Medi-Cal (Denti-Cal) Provider Number: ______________________________________
National Provider Identifier (NPI):
______________________________________
Printed Name of Dentist: __________________________________________________
Signature of Dentist: ___________________________ Date Signed: ______________
Please return this form to: Department of Health Care Services, Health Care Options, P.O. Box
989009, West Sacramento, CA 95798-9850 or FAX to (916) 364-0287, Attention: Research Unit
SA_0003539_ENG_0707

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