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Dental Providers
Medi-Cal Dental
Care Coordination Referral Form
Care Coordination Referral Form
This form is used to request dental care coordination for Medi-Cal members.
Care Coordination Referral Form
1. Member's Name
2. Member's Legal Guardian (if applicable)
3. Member's Medi-Cal ID (BIC Number) if known
4. Date of Birth
5. Member's Gender
Woman
Man
Non-binary
Given Name
6. Member's Ethnicity
Select your answer
Cuban
Guatemalan
Mexican/Mexican American/Chicano
Puerto Rican
Salvadoran
Other Hispanic, Latino or Spanish origin
American Indian or Alaska Native
Asian Indian
Black or African American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hispanic, Latino or Spanish
Hmong
Japanese
Korean
Laotian
Native Hawaiian
Samoan
Vietnamese
White
7. Specify the Needs Tier Level (1, 2, 3, or 4)
Tier 1 – Orthodontic Referral - Member Has a Dental Home
Tier 2 – No abnormalities Noted - Member Needs a Dental Home
Tier 3 – Appearance of Caries and/or Other Periodontal Issues Noted
Tier 4 – Member is in Pain Due to Dental Needs and/or Profound Urgent Needs Visible
8. What dental treatment does the member need?
Diagnostic and Preventive (procedures such as x-rays, exams, and routine cleanings)
Restorative Care (procedures such as cavity fillings)
Endodontics (procedures such as root canals)
Periodontics (procedures such as scaling and root planing and periodontal maintenance)
Prosthodontics (procedures such as full and partial dentures)
Emergency Services (emergency services if the member is in pain or immediate need of a dentist)
Orthodontics
Pediatric Dental
Oral Surgery (procedures such as extractions)
Number Of Dependence
9. Is this a member with special healthcare needs that may require general anesthesia?
Yes
No
10. If you believe this is a member with special healthcare needs that may require general anesthesia, please list the reason(s)
11. Does the member need translation or interpreter services?
Yes
No
12. If the member does need translation or interpreter services, please list the language
13. Does the member need transportation services to and from the appointment?
Yes
No
14. If the member does need transportation services, please list if they need medical transportation (such as paratransit) or non-medical type transportation
15. Requestor's Name
16. Requestor's Relationship to Member
General Dentist
Dental Specialist
Physician
FQHC/IHC/IFQHC/RHC
RDH/RDHAP/RDHEF
Community Health Worker
Medical Emergency Department
Medi-Cal Managed Care Plan
LOHP
School Nurse
Member/Member Representative
17. Requestor's Email
18. Requestor's Phone Number
