Dental Services Referral Form
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1HEALTHPLEX
333 Earle Ovington Blvd., Suite 300
SPECIALIST REFERRAL FORM
Uniondale, New York 11553- 3608
PATIENT NAME:
RELATIONSHIP TO MEMBER:
PATIENT BIRTHDATE:
MO
DAY
YR
SELF
SPOUSE
CHILD
OTHER
MEMBER NAME: LAST
FIRST
MI
MEMBER ID #
NAME OF GROUP DENTAL PROGRAM:
GROUP #:
MEMBER MAILING ADDRESS:
CITY
STATE:
P
R
O
V
REFERRED BY DR.:
PROVIDER SITE #: _______________
I
TOOTH #,
D
HEALTHPLEX
LETTER,
SERVICES REQUESTED
E
USE ONLY
OR AREA
R
Additional Information:
I understand that only those services approved by Healthplex will be covered by my Dental Plan.
Signature of Patient:
H
For Healthplex Use Only:
Referral:
Approved
Denied
Pending
E
A
Date Reviewed: _________________By ________________
L
T
Remarks: ___________________________________________________________________________
H
II
P
__________________________________________________
L
__________________________________________________
E
_____________________________________________________________
X
S
P
REFERRED TO DR.: _______________________________________________
SPECIALTY:_______________
E
C
ADDRESS: ______________________________________________________
TELEPHONE #:_______________
I
A
CO-PAYMENT: $_________________________________________
REFERRAL APPROVAL #:_______________
L
I
Please submit a claim form referencing the referral approval # to Healthplex for services rendered.
S
_____________________________________________________________
T
Referrals are not a guarantee of payment. Bene ts are subject to eligibility &
RIGHT
MAXILLARY
LEFT
plan limitations at the time of actual treatment.
INSTRUCTIONS:
1
2
3
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FOR NON-EMERGENCY REFERRALS:
1.
GP completes ‘PROVIDER’ section and submits form to Healthplex for review via mail, fax
to 516-228-5025, or email to .
2.
Healthplex reviews the request and issues a determination via mail to the GP and member.
A B C D E
F G H I J
Specialist will receive a copy if approved.
DECIDUOUS
DECIDUOUS
3.
If the referral is approved, the patient should make an appointment with the specialist.
T S R Q P
O N M L K
4.
The specialist renders approved services and submits a claim to Healthplex.
FOR EMERGENCY REFERRALS:
1.
GP completes ‘PROVIDER’ section and calls Healthplex for a referral approval number and
copayment information (to be placed in ‘SPECIALIST’ section).
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32 31 30 29 28 27 26 25
2.
The patient makes an appointment with the specialist and references the referral approval
# given by Healthplex.
MANDIBULAR
3.
The specialist renders approved services and submits a claim to Healthplex.
Revised 9/11
F-2053
Print 5/12
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Parent category: Medical