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

6. Member's Ethnicity

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)

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