Referral Form (Page 3 of 7) in pdf

Referral Form Page 3

ACCESS ONE, INC

DENTAL REFERRAL FORM

(609) 927-6662 Fax (609) 927-2942

REFERRAL FORM

Issue Date: ____________________

Approval : _________________

Number of Visits: _______________

Expiration Date: ____________

Patient Information:

Name: ________________________

DOB:______________________

Social Sec. #: __________________

URN#:_____________________

Diagnosis/Procedure:

________________________________________________________________________

Primary Care Physician:

Name: _________________________________________________________________

Address: _______________________________________________________________

City, State: _____________________________________________________________

Referred To Physician/ Facility Information:

Physician/Facility: UMDNJ @ University Dental Center at Galloway____________

Specialty: Dentist________________________________________________________

Address: _____________________________________________________________

City, State: _____________________________________________________________

To the Patient: Authorization must be obtained by Access One prior to receiving dental services.

If you obtain services without appropriate referral/authorization, understand that services may be

denied.

To the Provider: These services have been approved and are being funded by the Ryan

White Care Act Title III. If additional procedures and/or visits are needed, pre-approval

must be obtained from Access One’s Grant Administration (609) 927-6662.

3 - University of Medicine and Dentistry of New Jersey, NJ Dental School 973.972.0190

Tool Posted in the Ryan White TARGET Center TA Library,

Referral Form Page 3