Health Net Dental Specialist Referral Form Page 2

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Case Type I, II, III, IV
Dates of Root Planing
Uncooperative
UR _____
LL______
Date of treatment attempt ______
LR ______
LR _____
Medical Reason ___________________
Other ____________________________
See MD attached note
Other ____________________________________
___________________________________
____________________________________________
 Orthodontics Notes:
TREATMENT REQUEST
Tooth #
Surface
ADA Code
Description
Fee
Co-Pay
Dentist Signature ___________________________________________ Date _______________
In office use only
Date Received _____________ Eligibility _____________ Plan # ____________
Date Processed _____________
Approved 
Denied 
Modified 
X-rays reviewed _________________________ Tracking # ______________________
Comments_____________________________________________________________

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