Before considering referring a patient to PDI for dental surgery services requiring anesthesia, please read through the following carefully.  Check where applicable.

  1. Patient must meet the following criteria:
    1. Eligible patients as of January 2008: 
      1. The surgery center provides the following dental care under general anesthesia: Filling Cavities, Crowns, and Extractions.
      2. Must be age 18 months to 6 years (patients age 7 and older without documented disabilities must be referred elsewhere).
      3. Currently, only MediCal Patients are being scheduled. We are in the process of contracting with other insurances.
      4. We will begin scheduling older children and adults with special needs in Spring 2008*

*  Special Needs include autism, CP, mental retardation and Down’s Syndrome.

    1. Severity: There is no specific number of cavities that a patient must have.  Referring providers are asked to make a determination of whether putting a child under general anesthesia is necessary for dental treatment.  Previously unsuccessful attempts to treat the cavities by another dentist may also be considered in deciding to schedule the child for treatment.
    2. Insurance: Patients must be currently enrolled in MediCal.  Other insurances will be accepted shortly (including Healthy Families, Calkids, Partnership, and others).
    3. Uninsured patients: If all available insurance options have been pursued and coverage is still unavailable, a PDI case manager should be contacted.
  1. The following forms must be completed by the person indicated and returned to PDI to determine eligibility:
    • Dental Surgery Referral Form – Completed by the referring dentist
    • Dental Screening Form – Completed by the referring dentist (If you have your own treatment plan for this patient, you may substitute it in place of this form)
    • Pediatric Anesthesia Questionnaire – Completed by the patient’s parent or legal guardian
    • Copy of medical and dental insurance Card - faxed to PDI
  1. PDI case managers will work with the referring case manager/agency to coordinate and discuss the following with the family and ensure privacy practices are upheld:
    • Required pre- and post-operative dental and medical examinations
    • History and Physical Form - Completed by the primary care physician if determined necessary by the anesthesiologist due to a patient’s medical condition.
    • Authorizations to Use or Disclose Protected Health Information – Signed by the parent/guardian
    • Acknowledgement of Receipt of Notice of Privacy Practices – Signed by the parent/guardian
    • Parent/Legal Guardian Consent and Release Form – Signed by the parent/guardian
    • Transportation and Scheduling
    • Overview of the surgery and pre-op steps (food, medication, etc.)
    • Ask if a dentist or anesthesiologist has discussed the procedure with the family
    • Contact Family and remind them when it's time for their 6 month dental exam
    • Help Family find a local dental home, if necessary

 

If you have any questions or need additional materials, please contact Wendy Lopez at 707-837-8833, or by e-mail at wlopez@pedidental.org