Specialty Referral Form printable pdf download

SPECIALTY REFERRAL REQUEST FORM

** THIS FORM IS TO BE COMPLETED BY THE PCD AND SIGNED BY THE MEMBER, PCD & SPECIALIST **

Select one of the following:

Direct Referral

Pre-Authorization

Authorization #: ____________________

Date: ___________________________



FCW IL/IN/MI/MO

(866) 494-4542

P.O. Box 2448

Spokane, WA 99210-2448



MDC CA

(800) 273-3330

P.O. Box 4391

Woodland Hills, CA 91365-4391



MDG TX

(888) 618-2016

P.O. Box 4391

Woodland Hills, CA 91365-4391



MDG All Other States

(888) 618-2016

P.O. Box 2542

Spokane, WA 99210-2452



Guardian Individual Plan

(844) 561-5600

P.O. Box 254888

Sacramento, CA 95865-4888

Office ID#: ______________________ Referring PCD: __________________________________________________________

Phone#:________________________

PCD E-mail Address:_____________________________________________________

Patient Name: _____________________________________Date of Birth: _______________

Plan #: ___________________

Subscriber Name: __________________________________ ID #: _______________________ Emergency:

Yes

Subscriber Street Address:__________________________ City/State:__________________

Zip:__________________

Primary Care Dentist (PCD): Referral must be made to a network specialist. If there is no network specialist available, you must obtain prior

authorization from the Plan. All referrals must be made in compliance with Plan Referral Guidelines. The PCD is responsible for the cost of

covered services referred to non-participating specialists or for those services designated to be the responsibility of the PCD, unless prior

authorization has been obtained from the Plan. Please have the member sign and date all Specialty Referral Request Forms. All necessary

diagnostic x-rays must be attached and sent to the network specialist.

Network Specialist: Only the covered services referred by the PCD and listed on this form will be considered for payment. You may request

authorization for any service not listed on this referral form by submitting a pre-authorization on an ADA approved claim form. Please attach

this Specialty Referral Request Form and submit with a dated and signed claim form.

Specialty Care Benefits will only be considered for referable services listed on the applicable plan schedule and as explained in the

Specialty Referral Guidelines Section of the Network Operations Manual.

*****************************************************************************************************************************************************************

Some important Specialty Referral Guidelines are listed here for your convenience:



Endodontics: Uncomplicated anterior (D3310) and bicuspid (D3320) root canals are the responsibility of the PCD.



Oral Surgery: Routine (D7140) and uncomplicated surgical (D7210) extractions are the responsibility of the PCD. Referral of routine or

uncomplicated surgical extractions for general anesthesia and extraction of asymptomatic or non-pathological 3

molars are not covered.



Pediatric Dentistry: Routine care for children is the responsibility of the PCD.



Periodontics: A comprehensive treatment plan, preliminary therapy (including therapy to achieve control of local factors) and scaling and

root planing (D4341), where appropriate, are the responsibility of the PCD.

*****************************************************************************************************************************************************************

Specialty Requested:

Endodontics

Oral Surgery

Orthodontics

Pediatric Dentistry

Periodontics

Refer To Network Specialist:

Office ID: ____________

Specialist E-mail Address: ___________________________________________________________ Phone:____________________

Street Address:

____ City/State :

____________Zip: __________

Consultation only

Evaluation and Treatment

Emergency

Procedures Requested (attach additional form, if necessary):

Tooth # / Area

CDT Code

Tooth # / Area

CDT Code

Tooth # / Area

CDT Code

List circumstances requiring specialty referral for the requested services; please include all clinically relevant information:

___________________________________________________________________________________

Patient Informed Consent for Referral: Your PCD has requested a referral for the specialty care services listed above. For covered services,

the patient is responsible for the applicable plan schedule charges at the time of service. For non-covered services, the patient is responsible

for the network specialist’s usual fee. This referral is not a guarantee of coverage or benefit payment. The patient must be eligible at the time

of service and the Plan’s benefits, specialty referral guidelines, limitations and exclusions will determine coverage in all cases

Patient (or Guardian) Signature:

Date:

______

PCD Signature: __________________________________________________________________ Date: _______________

Specialist Signature: ______________________________________________________________ Date: _______________

Rev. 05/01/14

Specialty Referral Form

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