Get Form 3671-j.pdf - The Texas Department Of Aging And Disability ... - Dads State Tx

Filling out the Form 3671-J is an important step in securing dental services for individuals in need. This guide provides clear instructions on each section of the form to ensure the submission process is smooth and efficient.

Follow the steps to properly complete Form 3671-J.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by entering the applicant or individual's full name in the designated field. This should reflect the name as it appears on official documents.
3. Input the Medicaid number of the applicant. Ensure accuracy to avoid any delays in processing.
4. Fill in the date of the dental evaluation. This date is crucial for medical record keeping and planning.
5. Provide the complete address of the applicant or individual. Check for correctness as this will be used for future correspondence.
6. Enter the dentist's telephone number along with their address and email address. Make sure these details are current and reachable.
7. Specify the proposed date of services. This helps in scheduling the required dental care.
8. In the section outlining dental services needed, describe the dental problems of the individual and include medical necessity details. This information is essential for justifying the treatment plan.
9. Indicate whether the treatment plan requires the services of an oral surgeon by selecting 'Yes' or 'No.' If 'Yes,' provide the name of the oral surgeon and the date of the referral.
10. Complete the Dentist ID field with the appropriate identification number for the dentist providing the treatment.
11. Ensure the dentist signs and dates the form where indicated, confirming their approval of the proposed treatment plan.
12. Obtain the necessary signatures for agreement from the individual or their representative and the guarantor or Home and Community Support Services provider. Each party should date their signature.
13. Provide an estimated cost breakdown, indicating the costs related to the proposed treatment. If needed, attach additional pages to offer more details.
14. After completing all fields, save your changes, download the form for your records, print it for submission, or choose to share it as required.

Take the first step towards arranging dental services by completing Form 3671-J online today.