COUNTY OF ORANGE

HEALTH CARE AGENCY

Oral Health Care Referral

Ryan White Treatment Modernization Act

To assure eligibility and coordination of services, referrals for oral health services may only be initiated by a Ryan White-funded medical or case management provider. A new referral is required every six (6) months. Eligibility expires six (6) months from the date of the complete referral form as indicated below.

Referral to (Check one):

Health Care Agency (HCA) Dental Clinic 17th St. Santa Ana: Fax (714) 834-8377 Phone (714) 834-8408

Other (See “Ryan White Dental Referral Process for Providers” for list of other dental providers): ______

Today’s Date: ______Client’s ARIES ID: ______

Client Name (print): ______DOB: ______

First MI Last

Client’s Address: ______

City: ______ZIP Code: ______

Client’s Preferred Phone: ( ) ______Call OK? Yes / No Discretion? Yes / No

Special Needs (wheelchair, impaired vision, cognitive issues, other): ______

ALL THREE (3) CRITERIA MUST BE MET IN ORDER FOR THE REFERRAL TO BE ACCEPTED:

Client signed authorization which allows referring provider to disclose patient protected health information (PHI) to Dental provider is attached. Clients shall be informed of their right to: confidentiality in accordance with state and federal laws and informed consent.

I, as the person making this referral, have ensured that eligibility has been verified and all required documents (verification of HIV and proof of residence within Orange County) are present and filed in the eligibility section of the client file at the referring agency.

I, as the person making this referral, have ensured that Ryan White funds are the payer of last resort. Based on the information provided by the financial assessment and the client’s self-report, the client is not eligible* for the following:

Denti-Cal Medical Services Initiative (MSI) Private dental insurance

*MSI services are inappropriate or inaccessible

Person/Agency Referring

______

Name of Person Making Referral (Print) Title

______

Signature of Person Making Referral Date

Referring Agency (circle one): 17th Street Care Clinic ASF Delhi HCA Dental Clinic LBCC REACH Shanti OC

Referring Agency’s Phone: ( ) ______

F042-22.0065 (Revised 2/23/12)