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If you are not the intended recipient please return the original message and notify Mercy Care Plan immediately. Fax 602 798-2576 or 602 431-7555 or Toll Free 800 217-9345 Mailing Address 4350 E* Cotton Center Blvd Building D Phoenix AZ 85040 DENTAL PRIOR AUTHORIZATION REQUEST FORM COMPLETE ALL MEMBER DATA BELOW Member Name Member ID Number Member Address Member Date of Birth Member Phone Number MCP/AHCCCS Member MCP DDD/ALTCS Member COMPLETE ALL DENTAL PROVIDER DATA BELOW Requesting Dentist Name Provider ID Number Office Address Office Phone Office Fax Office Contact CHECK THE APPROPRIATE REQUEST Please write clearly TREATMENT PLAN The entire proposed treatment plan exceeds 1 000 and/or requires prior authorization* Attach the proposed treatment plan with cost estimates. Include additional documentation as required per the Dental Provider Manual and/or Dental Matrix. Emergency services that do not receive a prior authorization will be retro-reviewed for appropriateness. The prior authorization number must be written on the dental claim for processing* SPECIALTY REFERRAL Pedodontist Oral Surgeon Endodontist Other MCP Dental Specialist Name Reason for Referral Diagnosis and Tooth Number if applicable Medical Alert/Special Needs X-rays Enclosed X-rays to be returned to provider MCP USE ONLY Prior Authorization Number Auth Expiration Date Comments Approval Signature Date Signed VERIFY MEMBER ELIGIBILITY ON EACH DATE OF SERVICE CONFIDENTIALY NOTICE The information contained in this transmission is private. It may also be legally privileged and/or confidential information of Schaller Anderson or a third party authorized only for the use of the intended recipient. Fax 602 798-2576 or 602 431-7555 or Toll Free 800 217-9345 Mailing Address 4350 E* Cotton Center Blvd Building D Phoenix AZ 85040 DENTAL PRIOR AUTHORIZATION REQUEST FORM COMPLETE ALL MEMBER DATA BELOW Member Name Member ID Number Member Address Member Date of Birth Member Phone Number MCP/AHCCCS Member MCP DDD/ALTCS Member COMPLETE ALL DENTAL PROVIDER DATA BELOW Requesting Dentist Name Provider ID Number Office Address Office Phone Office Fax Office Contact CHECK THE APPROPRIATE REQUEST Please write clearly TREATMENT PLAN The entire proposed treatment plan exceeds 1 000 and/or requires prior authorization* Attach the proposed treatment plan with cost estimates. Include additional documentation as required per the Dental Provider Manual and/or Dental Matrix. Emergency services that do not receive a prior authorization will be retro-reviewed for appropriateness. Include additional documentation as required per the Dental Provider Manual and/or Dental Matrix. Emergency services that do not receive a prior authorization will be retro-reviewed for appropriateness. The prior authorization number must be written on the dental claim for processing* SPECIALTY REFERRAL Pedodontist Oral Surgeon Endodontist Other MCP Dental Specialist Name Reason for Referral Diagnosis and Tooth Number if applicable Medical Alert/Special Needs X-rays Enclosed X-rays to be returned to provider MCP USE ONLY Prior Authorization Number Auth Expiration Date Comments Approval Signature Date Signed VERIFY MEMBER ELIGIBILITY ON EACH DATE OF SERVICE CONFIDENTIALY NOTICE The information contained in this transmission is private.

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