Referring to a Mobile Dentist with a 1263

For dental referrals for Medicaid patients, completed and accurate H1263B forms are absolutely necessary. Here is a comprehensive guide for how to complete an H1263B from correctly for a mobile dentist. If you have any questions, please contact our office.

Page 1

1. Write the name and address of the attending physician in the upper left corner.

2. Write the name of the patient.

3. Write the client number in the box marked “client number” – This is the same as the Medicaid number. 

4. Write your facility name, address, and phone number (if you’re sending a face sheet with the H1263B, you can    skip this step).

5. In the box marked “Dental Services”, use the following words: Routine Dental Care-EXAM, XRAY, PX, and Further Treatment If Needed.

6.  Attending physician signature must be provided.* The physician’s name, type of practice, phone number and address must also be included.

7. In the section “TO BE COMPLETED BY ATTENDING PRACTITIONER”, notice that under the box in which dental services will be listed that there is the phrase “is/are not medically contraindicated for the patient”. Make sure that the words “is/are not” have been circled by the physician.

Page 2

1. Under section 1, write the patient’s name.

2. Under “I authorize”, write “Brown Dental Health Mgmt, P.O. Box 122295, Fort Worth, TX 76102. 817-335-5555.

3. Under section II, provide signature of responsible party, power of attorney, or patient (if self responsible).

4. Disclose address and phone number of the Responsible Party or power of attorney.

*Page1, Step 6: A nurse practitioner or physician’s assistant may sign this section for the attending physician. However, he or she must provide the physician’s name, address, and phone number – then he or she must sign their name and license number on the form. A DON (director of nursing) may also sign their name and license number in the event of an emergency.

Note: If you don’t want to get signatures from the RP (responsible party) and/or the physician, let us know! We can complete your paperwork for you. This may delay treatment, but we’re pleased to serve you. If you would like us to get these signatures for you, please fax or mail us a copy of the face sheet.

Contact Our Mobile Dentist – 817 335 5555

If there’s anything our office can do to help you in the mobile dentist referral process, please contact Brown Mobile Dental. It’s our delight and pleasure to serve you in any way that we can.