Refer a patient to a dentist

Send the dental office the clinical reason, the medical date that matters, and a secure link for the written report back. No account is required.

Before you start: The dentist must be Medicare-enrolled before providing the linked dental service.

Paste the note

Paste the consult note, the operative report, or the referral order

Every field stays editable, and you sign at the bottom.

The note is read to fill the form. It is not stored as the note, and nothing is sent to the dental office until you sign.

The referral

Patient name

Date of birth

Proposed medical procedure date

Qualifying condition

Clinical rationale

Where it goes

Dentist or practice name

Secure-link email

Fax

One channel is enough. The dentist needs no account to answer.

Patient contact, physician details and ICD-10 codes

Gender

Phone

Address

Referring physician

Medicare PIN

NPI, if you have it

Email for the returned report

Fax for the returned report

Provide at least one return channel.

ICD-10 code 1

ICD-10 code 2

ICD-10 code 3

Other condition, if selected above

Referral date

Written follow-up from the dental office is requested.

Sign

I attest that this information is accurate and that I am authorized to make this clinical referral.

Signer name

Electronic signature

Medical-side fields are modeled on the ADA's 2025 sample Referral for Dental Care (Medicare). The ADA notes that MACs are currently not requiring the sample form or other documentation with the claim, but may request supporting information later. CMS stated in the CY2023 PFS final rule (87 FR 69673) that without an exchange of information between the medical and dental professional there is no inextricable link, Since 2025-01-01 MACs may deny dental claims lacking the KX modifier attesting coordination occurred, and since 2025-07-01 that modifier is mandatory (CR 13649).