Health Net Specialty Care Referral Request

Health Net
Specialty Care Referral Request
P.O. Box 26110
Santa Ana, CA 92799-6110
Phone (888) 273-2713 Fax (949) 253-0096
Refer[email protected]bertydentalplan.com
Rev. 2/5/2014
Specialty Referral (Mail to Health Net with x-ray & documents) Emergency Referral (fax or email with x-rays & documents)
Provider Referring Specialist
Name: Specialist Name:
Phone: ID#: Phone: ID#:
Address: Address:
City, State, Zip: City, State, Zip:
Member
Member Name: ID #:
Patient Name: DOB:
Address: Phone:
City, State, Zip:
Treatment Request
CDT Code Description Tooth # Surface
PLEASE CHECK ALL THAT APPLY IN EACH SPECIALTY CATEGORY:
Endodontics
(must submit PA & BWX)
Prognosis (circle one): good / poor
Reason for Referral
Additional Information
Oral Surgery
(must submit PA or Pano)
Reason for Referral
Additional Information
*In absence of Pathology extractions of impacted teeth and roots are not a benefit
Pedodontics
If child is over 4 years old and uncooperative, please note attempts to treat (Children under 4 require
only one attempt if uncooperative):
Dates __________&__________
Age of Child _____________
Reason for Referral
Additional Information
Periodontics
(must submit FMX & perio
charting)
Referral limited to D9310 Consultation – diagnostic service provided by dentist or physician other than
requesting dentist or physician
(circle one)
Case Type I, II, III, IV
Dates of Root Planing
UR _________________ UL _________________
LR __________________ LL __________________
Additional Information
Orthodontics
Notes:
I hereby certify that the above noted treatment request has met the criteria for specialty referral and acknowledge that the final claim for
payment is subject to clinical review.
Dentist Signature: ___________________________________________________________ Date: ___________________________
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Health Net Specialty Care Referral Request PDF

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