Dental Case Management Referral Form

This form must be completed by the member’s medical provider, dental provider, case worker or healthcare care professional. Members cannot self-refer and must meet the criteria for case management to be considered for Medi-Cal Dental case management services.

Section 1: Member Information

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

Section 2: Referring Provider/Agency Information

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

Section 3: Criteria/Other Service Provider/Medical Plan Information

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

Criteria to become eligible for Case Management

Other Service Provider

Medical Plan Information

If Yes, please provide the following: