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)