Get 8666161475

Filling out the 8666161475 form online is essential for obtaining specialty dental care under the Delta Dental Utah Medicaid Dental Program. This guide provides straightforward instructions to help you navigate each section of the form, ensuring that all necessary information is captured accurately.

Follow the steps to complete the 8666161475 form online successfully.

1. Press the ‘Get Form’ button to access the form and display it in your browser.
2. In the Referral Information section, select the type of referral by checking the appropriate box: Endodontist, Oral Surgeon, Periodontist, Pediatric Dentist, or Orthodontist. Then, enter the referral number and the date.
3. In the Patient Information section, indicate if the primary enrollee is the patient by selecting 'Yes' or 'No.' If applicable, provide the last name, first name, and middle initial of the primary enrollee, as well as their date of birth.
4. Complete the Primary Enrollee Information section with the last name, first name, complete address, city, state, zip code, group/plan number, and ID number.
5. Fill in the daytime and work phone numbers for the primary enrollee. Also, indicate if the patient has additional dental coverage by selecting 'Yes' or 'No.' If 'Yes', provide the other dental carrier’s name and the policy holder’s details, including their name and ID.
6. In the Referring Facility Information section, indicate whether the contracted specialist is unavailable by selecting 'Yes' or 'No.' Specify if X-rays have been sent with the referral.
7. Provide the name, specialty number, phone number, and address of the referring facility along with the reason for the referral and any additional comments.
8. Document the procedure number, description, tooth number, and patient copayment in the designated section.
9. Ensure that both the patient and the referring dentist sign and date the form at the bottom.
10. Once all information is filled in, review the form for accuracy. You can save changes, download, print, or share the completed form as necessary.

Complete the 8666161475 form online now to ensure a smooth dental referral process.