Fillable Printable Health Net Specialty Care Referral Request
Fillable Printable Health Net Specialty Care Referral Request
Health Net Specialty Care Referral Request
Health Net
Specialty Care Referral Request
P.O. Box 26110
Santa Ana, CA 92799-6110
Phone (888) 273-2713 Fax (949) 253-0096
Referrals@libertydentalplan.com
Rev. 2/5/2014
Specialty Referral (Mail to Health Net with x-ray & documents) Emergency Referral (fax or email with x-rays & documents)
Provider Referring Specialist
Name: Specialist Name:
Phone: ID#: Phone: ID#:
Address: Address:
City, State, Zip: City, State, Zip:
Member
Member Name: ID #:
Patient Name: DOB:
Address: Phone:
City, State, Zip:
Treatment Request
CDT Code Description Tooth # Surface
PLEASE CHECK ALL THAT APPLY IN EACH SPECIALTY CATEGORY:
Endodontics
(must submit PA & BWX)
Prognosis (circle one): good / poor
Reason for Referral
Additional Information
Oral Surgery
(must submit PA or Pano)
Reason for Referral
Additional Information
*In absence of Pathology extractions of impacted teeth and roots are not a benefit
Pedodontics
If child is over 4 years old and uncooperative, please note attempts to treat (Children under 4 require
only one attempt if uncooperative):
Dates __________&__________
Age of Child _____________
Reason for Referral
Additional Information
Periodontics
(must submit FMX & perio
charting)
Referral limited to D9310 Consultation – diagnostic service provided by dentist or physician other than
requesting dentist or physician
(circle one)
Case Type I, II, III, IV
Dates of Root Planing
UR _________________ UL _________________
LR __________________ LL __________________
Additional Information
Orthodontics
Notes:
I hereby certify that the above noted treatment request has met the criteria for specialty referral and acknowledge that the final claim for
payment is subject to clinical review.
Dentist Signature: ___________________________________________________________ Date: ___________________________
