Get Texas Ict Form

Filling out the Texas Ict Form online is a straightforward process that allows Main Dental Home Assigned Providers to transfer patient care temporarily to another dentist. This guide will provide you with clear, step-by-step instructions to ensure that the form is completed accurately.

Follow the steps to complete the Texas Ict Form online

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter the date at the top of the form to indicate when the transfer request is being submitted.
3. In the 'Main Dental Home Assigned Provider Information' section, include your first name, last name, address, NPI number, city, state, zip code, and area code with your phone number.
4. Provide the member information. Ensure that the member is assigned to you as their Main Dental Home Provider by filling in their first name, last name, address, date of birth, state, member ID, and area code with phone number.
5. Select the transfer care dentist type by indicating whether the provider is a Pediatric Dentist or a General Practitioner.
6. In the 'Transfer Care Provider Information' section, complete all fields, including the transfer care provider's first name, last name, address, NPI number, service office location name, city, state, zip code, and area code with phone number.
7. Provide a description and reason for the interim care transfer. This includes specifying the tooth number and detailing the request.
8. After reviewing all information for accuracy, save your changes. You may also choose to download, print, or share the completed form as needed.

Complete the Texas Ict Form online today for efficient patient care transfer.