Skip to content
Read Our COVID-19 Procedures On How We Safely Deliver Care
CLOSE
X
About Us
Core Values
Our Dentists
Our Team
Careers
Locations
Patients
Caregivers & Families
How It Works (Patients)
New Patient Registration
Partners
Medicare Advantage Programs
PACE Programs
Senior Communities & Group Facilities
Texas Skilled Nursing Facilities
HCS & Special Needs Facilities
How It Works (Partners)
Services
In-Person Services
Teledentistry
Payments
Resources
FAQs
Forms & Documents
News & Blog
Tooth Chart
(866) 988-4504
Contact Us
Patient Referral
Registration
open mobile menu
Contact Us
Patient Referral
Registration
About Us
Core Values
Our Dentists
Our Team
Careers
Locations
Patients
Caregivers & Families
How It Works (Patients)
New Patient Registration
Partners
Medicare Advantage Programs
PACE Programs
Senior Communities & Group Facilities
Texas Skilled Nursing Facilities
HCS & Special Needs Facilities
How It Works (Partners)
Services
In-Person Services
Teledentistry
Payments
Resources
FAQs
Forms & Documents
News & Blog
Tooth Chart
Patient Referral Form
"
*
" indicates required fields
Please Select Your Role In Submitting This Referral
*
Patient
Power of Attorney (POA)
Staff at a Community or Facility
Health Plan Representative
Other
Name Of Person Making This Referral:
*
Your Phone Number
*
What Organization Is Making The Referral?
*
Your Email
Patient Name
*
First
Last
Patient Location
*
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Patient Birth Date
*
MM slash DD slash YYYY
Where does the patient live?
*
Community or Facility
Personal Residence
What Type Of Community or Facility
*
Skilled Nursing Facility
Assisted Living Community
Memory Care Community
Special Needs
PACE Center
Other
Community or Facility Name
*
Dual Coverage?
*
Yes
No
Patient's Insurance Type
*
Medicare Advantage
Commercial Insurance
No Insurnace
Medicaid
Other
Patient Requires a POA (Power Of Attorney)
*
Yes
No
Name Of Plan
*
Name of Medicare Advantage Plan
*
United Healthcare/Optum
Cigna
Longevity
Provider Partners Health Plan
Health Plan of San Mateo
Other
Name of Medicaid Plan
*
Health Plan of San Mateo
Missouri HealthNet
Other
Name of Medicare Advantage Plan
*
Name of Medicaid Plan/Program
*
ID Number
*
Medicaid Program
*
R13 (Full Vendor)
R14
Other
Who Will Pay For The Services?
*
Facility
POA/Family Member
Open DME?
*
Yes
No
Applied Income Amount?
*
End Date
*
MM slash DD slash YYYY
Who Handles The Funds?
*
Facility
POA/Family Member
Financial Status With The Facility?
*
Current
Not Current
Unknown
Hospice?
*
Yes
No
POA Name
*
First
Last
POA Email
*
POA Phone
*
Patient Email
*
Patient Phone Number
*
How Can We Help?
*
Patient Consent
*
I agree to have Enable Dental contact me regarding "portable" dental services.
POA Consent
*
I agree to have Enable Dental contact me regarding "portable" dental services.
File Upload
Max. file size: 300 MB.
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
Had a great experience with Enable Dental? Leave us a review!