Care Coordination Referral Form
This form is used to request dental care coordination for Medi-Cal members.
Dental Care Coordination is designed to assist Medi-Cal members in locating a general or specialist dentist, scheduling appointments, translation services, and transportation assistance. A Medi-Cal Dental care coordinator will contact the Member within three (3) business days of form submission. To prevent delays, please complete this form accurately with as much detail as possible.