If you’re a social worker or DON, we want to assist you in the dental referral process in any way we can. Below are instructions for you to follow in setting up an appointment. Please follow them exactly. If there’s anything else we can do, please contact our office. It’s our pleasure to serve you.

For Medicaid Patients with Applied Income

1. Complete the Dental Referral Form.

2. Complete an H1263B form. (For instructions on how to do so, see “How to Complete an H1263B”)

3. Print patient’s Face Sheet and List of Medications.

4. Give each patient our Privacy Notice  form so that they can read about their rights to privacy under HIPAA.

5. Fax or email the Dental Referral for Medicaid Patients form, Privacy Notice and Acknowledgement of Privacy Notice form, Face Sheet, List of Medications, and pages 1-2 of the H1263B form to our office so that we can get prepared to schedule your appointment.

6. Mail pages 1-2 of the original H1263B form to our mailing address:

P.O. Box 122295, Fort Worth, TX 76121.

For Private Pay Appointments

1. Complete our Private Pay Agreement Form.

2. Sign our Privacy Notice form.

3. Fax/Mail the above forms to our mailing address. Include a check for the initial exam fee.

If you need assistance with or have questions regarding any of these steps, please contact our office. It will be our delight to help you in any way we can.


photo credit dcysurfer/Dave Young