Get Deltacare Specialty Referral

Completing the Deltacare Specialty Referral form can be straightforward with clear guidance. This guide provides step-by-step instructions to help users accurately fill out the form and ensure it meets all necessary requirements.

Follow the steps to accurately complete the Deltacare Specialty Referral form.

1. Press the ‘Get Form’ button to obtain the referral form and open it for editing.
2. Fill in the DeltaCare Member information at the top of the form, including the referral date, patient name, subscriber name, patient date of birth, subscriber SSN or alternate ID, group number, subscriber telephone number, group name, and plan ID.
3. Provide the details of the DeltaCare Primary Care Dentist, including the FC ID.
4. Enter information for the DeltaCare Specialty Dentist, such as facility name, SP FC ID, address, telephone, and fax.
5. Indicate the services requested by the Primary Care Dentist by filling in the quad/tooth, specialty dentist/facility name, and type of radiographs sent to the specialist, noting the number of periapicals (PAs), Panorex, or complete series sent.
6. Document the date the radiographs were taken and any relevant specialty services such as endodontics, pedodontics, oral surgery, or periodontics.
7. In the reason for referral section, clearly describe the justification for the referral.
8. Review and confirm all entries are complete and accurate to avoid delays. The Primary Care Dentist must sign and date the form, as well as the member/patient.
9. Once completed, save any changes made to the document. You may then download, print, or share the form as needed.

Complete your Deltacare Specialty Referral form online today for efficient processing.