Health Net Dental Specialist Referral Form

ADVERTISEMENT

Health Net Dental Specialist Referral Form
Health Net DENTAL
340 Commerce, Suite 100
Irvine, CA 92602
Specialty Referral
Emergency Referral
(Mail to Health Net with x-ray & documents)
(Call: (800) 977-7307 or Fax to Health Net)
Provider
Member
Provider #ID
Phone
Member Name
ID#
Name
Patient Name
Phone
Address
Address
DOB
City
City
CHECK ALL THAT APPLY IN EACH CATEGORY:
Endodontics (must submit PA & BWX)
Oral Surgery (must submit PA or Pano)
Prognosis ____________________
Pain
Pain
Swelling
Retreatment (date of original RCT ___)
Periocornitis caused by exacerbated third molars
Calcification (circle one)
Non-restorable – caries/internal resorption
Canal involved M D B P
Resorption of roots of adjacent teeth
Curved Canal (circle one)
Interference with prosthesis
Canal involved M D B P
of edentulous arches
Internal/External Resorption
Other ______________________________
Apicoectomy/Retrofiling
Other ___________________
In absence of Pathology extractions of
impacted teeth and roots are not a benefit
Periodontics (must submit FMX & perio
Pedodontics
charting)
(circle one)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2