River’s edge orthodontics

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Brad A. Pendell, D.D.S., M.S., L.L.C.

Specialist in Orthodontics

464 Shawnee Lane, Chillicothe, Ohio 45601

Telephone (740) 774-3343

CareSource Comprehensive Orthodontic Treatment Referral

Patient’s Name:____________________________________________

Referring Dentist:___________________________________________
Dental provider, please verify and check appropriate CareSource prior authorization requirements for comprehensive orthodontic treatment below.

□ 1. Member is 13 years old or older or has all permanent dentition present.

□ 2. Member has received an oral exam and was found to be free of caries, untreated oral disease, or other conditions that may make orthodontic treatment unsuccessful or harmful.

□ 3. Member demonstrates oral hygiene habits consistent with being able to prevent inflammation and dental decay during orthodontic treatment.

□ 4. Sealants are in place on all of the member’s unrestored erupted permanent molars.
Please note all above requirements need to be fulfilled or completed in order to be scheduled for an orthodontic evaluation.

Patient will need to bring this completed referral form to initial exam visit.

____________________________________________ _____________________

Treating Dentist’s Signature Date

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