Get Udc Referral Form

Specialty Care Referral Form UDC Dental California Inc. All pertinent specialty care information must be provided Date Patient name FIRST Address LAST MIDDLE STREET Subscriber Daytime phone CITY STATE ZIP CODE Patient D. O. B. Group Plan Referring Dentist Dentist I. D. Phone Participating Specialist Periodontics Periocharting Required Enclosed Items F*M. X-rays Perio Case Type Dates of Scaling Root Plaining Good Compliance with home care instruction Prognosis of Case Service Requested Eval Endodontics Fair Poor Surgery Yes Required P. A. X-rays enclosed No 3310 Anterior - Tooth Calcified Canals 3320 Bicuspid - Tooth Retreatment 3330 Molar - Tooth Other Complications 3410 Apico - Tooth Oral Surgery Required Panoramic X-rays enclosed 7210 Surgical Extraction - Tooth 7230 Partial Bony Impaction - Tooth 7220 Soft Tissue Impaction - Tooth 7240 Full Bony Impaction - Tooth Required Bitewing and Periapical X-rays enclosed Age of Child Orthodontics years Patient compliance to treatment Age of Patient Comments Please list complications prohibiting Family Dentist from performing the procedures requested Tooth Description ADA Code Approved Denied UDC DENTAL CALIFORNIA INC. USE ONLY / Date to Specialist UDC Signature Date Received Contract Compliance Member Eligibility Emergency UDC Dental Director X-Ray Retro Review Send to UDC Dental California Inc* 6310 Greenwich Drive Suite 210 San Diego CA 92122 Toll Free Phone 1. 800. 821. 1294 THIS REFERRAL IS ONLY VALID FOR 60 DAYS FROM THE DATE SENT TO THE SPECIALIST INDICATED ABOVE Current Dental Terminology American Dental Association SCRF-CA 05/98 KC4531CA 10/2009. O. B. Group Plan Referring Dentist Dentist I. D. Phone Participating Specialist Periodontics Periocharting Required Enclosed Items F*M. X-rays Perio Case Type Dates of Scaling Root Plaining Good Compliance with home care instruction Prognosis of Case Service Requested Eval Endodontics Fair Poor Surgery Yes Required P. X-rays Perio Case Type Dates of Scaling Root Plaining Good Compliance with home care instruction Prognosis of Case Service Requested Eval Endodontics Fair Poor Surgery Yes Required P. A. X-rays enclosed No 3310 Anterior - Tooth Calcified Canals 3320 Bicuspid - Tooth Retreatment 3330 Molar - Tooth Other Complications 3410 Apico - Tooth Oral Surgery Required Panoramic X-rays enclosed 7210 Surgical Extraction - Tooth 7230 Partial Bony Impaction - Tooth 7220 Soft Tissue Impaction - Tooth 7240 Full Bony Impaction - Tooth Required Bitewing and Periapical X-rays enclosed Age of Child Orthodontics years Patient compliance to treatment Age of Patient Comments Please list complications prohibiting Family Dentist from performing the procedures requested Tooth Description ADA Code Approved Denied UDC DENTAL CALIFORNIA INC. A. X-rays enclosed No 3310 Anterior - Tooth Calcified Canals 3320 Bicuspid - Tooth Retreatment 3330 Molar - Tooth Other Complications 3410 Apico - Tooth Oral Surgery Required Panoramic X-rays enclosed 7210 Surgical Extraction - Tooth 7230 Partial Bony Impaction - Tooth 7220 Soft Tissue Impaction - Tooth 7240 Full Bony Impaction - Tooth Required Bitewing and Periapical X-rays enclosed Age of Child Orthodontics years Patient compliance to treatment Age of Patient Comments Please list complications prohibiting Family Dentist from performing the procedures requested Tooth Description ADA Code Approved Denied UDC DENTAL CALIFORNIA INC. USE ONLY / Date to Specialist UDC Signature Date Received Contract Compliance Member Eligibility Emergency UDC Dental Director X-Ray Retro Review Send to UDC Dental California Inc* 6310 Greenwich Drive Suite 210 San Diego CA 92122 Toll Free Phone 1.