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H x-ray & documents) Referral # Emergency Referral (fax or email with x-ray & documents) Provider Referring Specialist Name: Specialist Name: Phone: ID#: Phone: Address: Address: City, State, Zip: ID#: City, State, Zip: Member Member Name: ID #: Eligibility Verified: Patient Name: DOB: Verifiers Initials: Address: Phone: Date & Time: Yes No City, State, Zip: Treatment Request CDT Code Procedure Code Description Tooth # Surface PLEASE CHECK ALL THAT APPLY.

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