General Dentist Referral Forms

PPOS

Fill out one of our colored RootVision Endo office referrals. Have your patient contact us or call us directly from your office to schedule an appointment.

Please refer to the chart below when referring your patient for their endodontic needs. Patients should be referred to the most convenient location; however, they may choose any one of our locations to have their treatment completed.

Please fill out the appropriate colored card once a location has been chosen and keep a copy for your office records.

• Yellow = GLENDALE
• Gold = LAKEWOOD
• Pink = MONTEBELLO
• Green = TORRANCE
• Blue = COVINA

HMO

1.Use our Pre-Completed Insurance Form and simply complete the Patient/GP Office portion of the Insurance Referral Form, along with any other necessary information regarding your patient’s care.

2.Information will include: Tooth #, procedure required- Consult only, Consult/Treatment; Consult/Open for Treatment

3.Include any additional comments that will better assist us in completing our Endodontic portion of the patient’s care (I.e. Post Build-up, Post Space, etc).

4.Please list contact #s for us to contact the patient (i.e. mobile, work, home, etc.)

Choose Insurance Provider:AetnaBlue Cross Dental NetBlue Cross SelectBlue Shield/Dental Benefit Provider HMOCignaDelta Care PMIGolden WestHealth NetLiberty Dental PlanManaged Dental CarePacificarePacific UnionSafeguardUnited ConcordiaWestern Dental

>> HMO Facility/Provider ID# Sheet

** For emergencies, immediately call the office location most convenient for your patient to schedule an appointment. **

For Non-emergencies, please fax the direct referral to the office location chosen for treatment so that one of our staff members can call your patient to schedule an appointment at their earliest convenience.

With these 4 easy steps, your patients will be well taken care of and wait time will be minimal. Patients can also download all office forms at the bottom of this page.