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Get Ga Deltacare Frm 0028 2011-2025
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How to fill out the GA DeltaCare FRM 0028 online
The GA DeltaCare FRM 0028 is a specialty care referral form designed for patients to facilitate their appointments with dental specialists. This guide provides step-by-step instructions to assist users in completing the form accurately online.
Follow the steps to fill out the GA DeltaCare FRM 0028 online effectively.
- Press the ‘Get Form’ button to access the GA DeltaCare FRM 0028 and open it in your preferred editor.
- In the Referral Information section, select the appropriate referral type by checking the box next to either Endodontist, Oral Surgeon, Periodontist, Pediatric Dentist, or Orthodontist. Fill in the Referral number and Date in the corresponding fields.
- Proceed to the Patient Information section. Indicate whether the patient is the primary enrollee, spouse, or dependent by selecting the appropriate option. Enter the Last Name, First Name, Middle Initial, and Date of Birth of the patient.
- In the Primary Enrollee Information section, complete the enroller's details by providing their Last Name, First Name, Address, City, State, Zip Code, Group/Plan Number, and ID Number.
- Fill in the Daytime Phone Number and Work Phone Number of the primary enrollee. Indicate if the patient has additional dental coverage by checking ‘Yes’ or ‘No’ and providing the name of the other dental carrier and policyholder details if necessary.
- In the Referring Facility Information section, indicate if a contracted specialist was unavailable by checking ‘Yes’ or ‘No.’ State whether X-Rays were sent with the referral, and complete the Referring Facility Name, Facility Number, Facility Phone Number, Specialist Name, Specialist Number, and Specialist Phone Number.
- Write the reason for the referral in the designated field. Add comments if necessary.
- For the Procedure section, outline the procedure number, description, tooth number, and patient copayment information as applicable.
- Obtain the required signatures from both the patient and the referring dentist, noting the date for each signature.
- Once all sections are completed, you can save your changes. You may also choose to download, print, or share the form.
Complete your documents online for seamless submission.
The waiting period for DeltaCare USA can vary based on your specific plan and coverage levels. Generally, it refers to the time frame before certain benefits under the GA DeltaCare FRM 0028 plan become active. It is crucial to check your policy details for exact timelines. For personalized assistance, platforms like US Legal Forms can offer valuable information.
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