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TennCare Inpatient and Outpatient Hospital Readiness Pre-admission Form This form is required to be submitted with documentation as outlined in Section 15.00, Criteria for Provision of Dental Treatment in a Inpatient/Outpatient Hospital (“Hospital”) Facility or in an Ambulatory Surgical Center (ASC) Date ________________________________________________________________ Patient Name ________________________________________________________ Patient Address _______________________________________________________ Patient ID # __________________________________________________________ A. I certify that I have examined this patient YES NO Date of exam ______________________________________________________ B. There is pathology or injury requiring extensive dental treatment (restorative or surgical) YES NO C. I certify that I have attempted to treat this patient in my office YES NO If yes, date of visit___________________________________________________ D. If a general dentist, I have attempted to refer this patient to a dental specialist (oral surgeon or pediatric dentist)? YES NO E. If no, why was a referral not made? F. Were x-rays taken to determine diagnosis? YES NO G. I have submitted all of the documentation required to submit a request for prior authorization as described in the TennFDUHOffice Reference Manual? NO YES H. If answer to “F” or “G” is no, please explain why the aforementioned documentation is not being submitted: ________________________________________________________________ CERTIFY THAT THE ABOVE INFORMATION IS CORRECT: Name of provider ______________________________________________________ Provider’s signature ___________________________________________________ Date ________________________________________________________________ Submit to: DentaQuest - TennCare Attn: Pre-authorizations 12121 N. Corporate Pkwy Mequon, WI 50392 FAX: 262.834.3575 or 888.313.2883 TennCare Dental Provider ORM Oct 2013