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Dental treatment referral form
Section 1 Requestor information
Request date (mm/dd/yyyy) Requestor name Requestor title
Requestor email Phone Fax
Organization name
Organization type (check one) � School � SBHC � County health � ER � Pediatrician’s office
Referrals NOT accepted from parent/legal guardian; must come directly from authorized organization
Section 2 Patient information
Patient last name First M.I.
Date of birth (mm/dd/yyyy) Is the child 5 to 18 years of age?
� Yes � No
Gender
� Male � Female
Primary language
Address
City State ZIP code County
Parent or legal guardian last name Parent or legal guardian first name Phone
Primary reason for referral
� Pain (abscess) � Tooth pain (unknown cause) � Restorative (cavity) � Preventative
Is the child a patient of record of a local dentist?
� Yes � No � Unknown
If yes, list dentist’s name If yes, list dentist’s city
Is the child covered under a dental plan?
� OHP � Commercial � None � Unknown
Has the child been referred to this program in the past?
� Yes � No � Unknown
Has the child’s parent or legal guardian been notified of this referral? � Yes � No
Referring party is responsible for notifying parent that child is being referred to The Children’s Program
For office use only
Referral status
� Accepted � Pending additional information � Does not qualify (list reason)
Member on file (previous referral)
� Yes � No
Current coverage checked
� O � F
Assigned
� ODS � WDG � KZ
Assigned dentist Phone
Notifed referring organization
� Yes � No
TCP referral processed (date & initial) B&E referral processed (date & initial)
The Children’s Program provides access to basic dental services on an as-needed basis for uninsured
children ages 5 to 18 who reside in Oregon. If eligible, each child will be assigned a dentist and may
receive care during his or her eligibility period. The child’s parent or legal guardian will receive a
letter notifying them of the child’s ID number and dentist’s name and phone number so they may
schedule an appointment. The assigned dental office will also receive a copy of the referral letter.
Ready to submit? Please fax the completed referral form to 503-382-5342 or 888-229-7140. Or email the completed form to
childrensprogram@modahealth.com. For more information, please contact the Children’s Program Coordinator at 503-265-5627
or 888-393-2772. Or email childrensprogram@modahealth.com.
