Missed Appointment Notification

The Missed Appointment Form is made available to you, as a Medi-Cal Dental Program dentist, in order for you to report members that have missed a scheduled appointment with your office. If you would like Medi-Cal to assist a member with any barriers they may have in attending their appointments, please complete this form. After Completion and submission of this form, Medi-Cal will follow-up with the member to assist in rescheduling their appointment with your office. Additional information related to missed appointments is located in the Provider handbook. If you would like to report a missed appointment by phone, please contact the Medi-Cal Dental Program Telephone Service Center at 1-800-423-0507.

Dental Provider Information

*Denotes required field. Enter "N/A" if no information available

*Billing NPI Number/Medi-Cal Provider ID

Service Office Number

*Contact Phone Number

*Contact Person

*Contact Email

Provider License Number (Optional)

Member Information

To add more than one Member, click on Add Member button below.

Member 1

*Last Name

*First Name

*Medi-Cal ID Number

*Date of Birth

*Patient Status

Member Representative Type

Member Representative Name

Language Spoken

Address

City

State

Zip Code

*Phone Number

Alternate Phone Number

Missed Appointment Information

*Appointment Date

*Appointment Time

*Has the member missed any prior appointments?

Yes

I verify that the information submitted here is true and accurate to the best of my knowledge.