Effective Date: 




Updated:  5/2017



This form helps counselors gather the necessary information to determine treatment needs for the consumer. This form may be used when purchasing a dental exam to obtain concise information about the consumer’s condition and treatment recommendations.


Copies and Distribution

No copies are required. The completed form is placed in the consumer’s paper file. If the consumer’s case is submitted to the regional dental consultant and/or the state medical consultant for guidance and/or a decision about services, a copy of the form is included in the courtesy file.



The completed form is part of the consumer’s paper file and is retained until the end of the fiscal year the case is closed, plus five years.


Acronyms and Definitions

ADA—American Dental Association


Special Instructions

This form is referenced in the Counselor Desk Reference, Chapter 10: Dental, 10.2.3 Required Consultations and Approvals for Dental Services.

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