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DentiCAL Form

 

 

More:

 

1 - Patients Name [last, first, mi]

2 - Patients Social Security #

3 - Patients Sex

4 - Patients Birth Date

5 - Patient MediCAL ID#

6 - Patients Address

7 - Patient Dental Record#

8 - Referring Provider#

9 - Radiographs Attached?

10 - Other Attachments

11 - Accident/Injury?

11 - Employment Related?

12 - Eligibility Pending? TAR ONLY

13 - Other Dental Coverage?

14 - Medicare Dental Coverage?

15 - Retroactive Eligibility?

16 - CHDP

17 - CCS

18 - Maxillofacial - Orthodontic

19 - Billing Provider Name

20 - Billing Provider Number

21 - Billing Provider Address/Phone

22 - Place of Service

23 - Proof of Elgibility

24 - Examination and Treatment

25 - Tooth Identification Chart

26 - Tooth # or Letter; Arch; Quadrant

27 - Tooth Surfaces

28 - Description of Service

29 - Date Service Performed

30 - Quantity

31 - Procedure Numbers

32 - Fee

33 - Treating Medi-CAL Provider #

34 - Comments

35 - Total Fee Charged

36 - Patient Share of Cost Amount

37 - Other Coverage Amount

38 - Date Billed

39 - Signature Block

TAR Treatment Authorization Request