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In cases of direct referral, the general dentist must complete the referral form and provide the original copy and all clinical documentation to the patient for transmittal to the participating specialty care dentist. Complete the form below and send it to the address listed for your state. I understand that i am responsible for deductible charges, copayments and all costs for services not covered by my dental health services plan

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Ii request authorization for the treatment described on this form, which in my professional judgment is necessary. Complete the appropriate section of the specialty referral form, attach supporting diagnostic material and submit to the appropriate aetna dental service center. This form can be completed to update your status at any time

Providers participating in medi‐cal dental are automatically listed in the provider directory as accepting new patient referrals unless they complete and submit this form indicating otherwise.

Liberty dental plan specialty care referral request p.o Oral surgery referral is considered for individual symptomatic or pathologically involved partial or full bony impactions, and difficult surgical or soft tissue extractions of pathologic/symptomatic teeth. Under these plans, referrals and preauthorization for payment by cigna dental are not necessary for care received at a network specialty dentist Cigna dental will not make payments toward this treatment.

The specialty dentist may report examination, treatment plan approval, or services rendered as follows