Get the free Dental Continuation of Care Request Form. Dental Continuation of Care Request Form

5/2019Dental Continuation of Care Request Form Crowns / Inlays / Inlays Note: Only eligible orthodontia, crowns, inlays and inlays will be considered for Continuation of Care exceptions. For orthodontia,

How to fill out dental continuation of care

How to fill out dental continuation of care

1. Obtain the dental continuation of care form from your dentist or dental provider.
2. Fill in your personal information, including your name, contact information, and date of birth.
3. Provide your dental insurance information, including the insurance company's name and policy number.
4. Indicate the reason for seeking dental continuation of care, whether it is for ongoing treatment, follow-up appointments, or specialist referrals.
5. Specify the dates and details of past dental treatments or procedures you have received.
6. Mention any medications or allergies that are relevant to your dental care.
7. Sign and date the form, confirming that the information provided is accurate to the best of your knowledge.
8. Make copies of the completed form for your records and submit the original to your dentist or dental provider.

Who needs dental continuation of care?

1. Anyone who wishes to continue receiving dental care from a specific dentist or dental provider may need to fill out a dental continuation of care form.
2. This form is commonly required when switching insurance plans, changing dental providers, or seeking ongoing treatment, follow-up appointments, or specialist referrals.
3. It ensures that your new dental provider has access to your dental history and can continue your care effectively.

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