This form is for patients with Delta Dental Wellness Plan for Kids ONLY, for all other referrals use our normal referral form.

□ Referring dentist understands that this practice does not offer in office treatment for Medicaid patients and is for dental surgery at surgery center or hospital.

□ Referring dentist understands that this practice is not in Network with Medicaid (DWPK Only) and each case performed on a single case agreement.  Referral does not guarantee case will meet criteria for treatment under general anesthesia.

□ Referring dentist understands that after treatment is completed the patient will be return to their dental home for routine care.