Download Referral Template for Primary Care Referrals to Dentistry

Referral Template for
Primary Care Referrals to Dentistry al Template for Primary Care Referrals to
Dentistry
Effective communication between primary care and specialist clinicians is essential to achieve care
coordination. This document includes suggestions for the type of information that should be shared between
primary care and dentistry to ensure a smooth referral process. Page 2 provides a modifiable template for a
referral form that can be faxed or scanned and securely emailed to support medical-dental referrals.
What information needs to accompany a referral from
primary care to dentistry?
The information needed to accompany a dental referral is the same as the information that accompanies a
medical-surgical referral. That information includes:
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Service requested of the dentist/reason for referral.
Demographic information, including medical and dental insurance status.
Additional relevant clinical information, such as:
 Problem list.
 Relevant past medical/surgical history (e.g., temporomandibular joint [TMJ] disease or sinus surgery).
 Current medication list.
 Current allergy list.
 Immunizations.
 Pertinent laboratory tests and imaging.
Primary care practices typically have a template for medical-surgical referrals. This should be modified, as
needed, and used for dental referrals as well.
What information should be sent back from the
dentist to the referring primary care clinician?
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Date the patient was seen.
What was found (e.g., caries in multiple teeth, or type of periodontal disease—periodontitis/gingivitis).
What was done (e.g., procedures, medications prescribed).
Brief treatment plan (e.g., three-quadrant scaling).
Follow-up plan.
Source: Developed by Qualis Health for the Washington Dental Service Foundation “Oral Health Preventive Services in Primary Care Project.”
1st ed. Seattle, WA. April 2016.
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Patient Information for Referrals
Primary Care
This referral order serves as medical authorization for this patient to receive appropriate dental treatment.
Date of referral:
Referring clinician:
PCP contact information:
Patient name:
Contact information:
Date of birth:
High risk for tooth decay due to family history [Y/N]:
Insurance status:
Reason for referral:
Pertinent medical information (problem list, medication list, allergy list):
Impression for patient to tolerate dental treatment:
Additional information attached (laboratory tests/images, etc.) [Y/N]:
Dentistry
Date patient was seen:
Reason for referral:
Dentist contact information:
Findings:
Today’s treatment:
Treatment plan:
Follow-up plan:
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About the Oral Health Integration in Primary Care Project
Organized, Evidence-Based Care Supplement: Oral Health Integration joins the Safety Net Medical Home
Initiative Implementation Guide Series.
The goal of the Oral Health Integration in Primary Care Project was to prepare primary care teams to address oral
health and to improve referrals to dentistry through the development and testing of a framework and toolset. The
project was administered by Qualis Health and built upon the learnings from 19 field-testing sites in Washington,
Oregon, Kansas, Missouri, and Massachusetts, who received implementation support from their primary care
association. Organized, Evidence-Based Care Supplement: Oral Health Integration built upon the Oral Health
Delivery Framework published in Oral Health: An Essential Component of Primary Care, and was informed by the
field-testing sites’ work, experiences, and feedback. Field-testing sites in Kansas, Massachusetts, and Oregon
also received technical assistance from their state’s primary care association.
The Oral Health Integration in Primary Care Project was sponsored by the National Interprofessional Initiative on
Oral Health, a consortium of funders and health professionals who share a vision that dental disease can be
eradicated, and funded by the DentaQuest Foundation, the REACH Healthcare Foundation, and the Washington
Dental Service Foundation.
For more information about the project sponsors and funders, refer to:
National Interprofessional Initiative on Oral Health: www.niioh.org.
DentaQuest Foundation: www.dentaquestfoundation.org.
REACH Healthcare Foundation: www.reachhealth.org.
Washington Dental Service Foundation: www.deltadentalwa.com/foundation.
The guide has been added to a series published by the Safety Net Medical Home Initiative, which was sponsored
by The Commonwealth Fund, supported by local and regional foundations, and administered by Qualis Health in
partnership with the MacColl Center for Health Care Innovation.
For more information about the Safety Net Medical Home Initiative, refer to www.safetynetmedicalhome.org
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