Get Referral Service - Dental Board Of California - State Of California - Dbc Ca

This guide provides clear instructions on how to complete the Referral Service application for the Dental Board of California. By following each step, you can ensure that your application is accurately filled out and submitted online.

Follow the steps to complete your application online.

1. Click ‘Get Form’ button to access the application form and open it in your preferred document editor.
2. Begin filling out the form by providing the name of the referral service. Ensure this is accurate and reflects the official name used in operations.
3. Input the complete address of the referral service, including the street, city, state, and zip code. Use a legible typing or clear handwriting method.
4. Enter the telephone number of the referral service and include a fax number if available. This information is crucial for communication.
5. Indicate the ownership structure of the referral service by selecting among the options: Individual dentist, group of dentists, dental society, or other. If selecting 'other', provide a description.
6. Answer yes or no to whether the referral service is a Knox-Keene Provider or associated with one. If yes, list the name of the Knox-Keene Provider.
7. Check yes or no to confirm if the referral service is a Provider Organization (PPO).
8. List the names of the owner(s) of the referral service. If there are additional names, note that they can be provided on a separate sheet.
9. Respond to questions regarding dentist participation, advertising compliance, and solicitation practices as specified in the form. Ensure answers are accurate.
10. Describe any fee arrangements between member dentists and the referral service, detailing enrollment and ongoing fees if applicable.
11. Attach a copy of the standard form contract that regulates the relationship with member dentists as required by Section 650.2.
12. In the certification section, affirm that all statements are correct, indicate the city and state of execution, and provide the current date. Remember to sign and print or type the name of the owner.
13. Review the information collection and access section, ensuring understanding of the agency's information management practices.
14. Once all sections are completed, review the entire document for accuracy. Save any changes made, and choose to download, print, or share the form as needed.

Start completing your Referral Service application online today to ensure a smooth submission process.