Dental Request for Prior Approval for Treatment or Referral to a Specialist

Form ID
D0986
Audience
For providers
Dental prosthetist
Dental specialist
Dentist
Medical specialist

Request for prior approval for treatment or referral to a specialist. Form may be referred to as D0986 or D986.

If you are using an Apple computer and want to fill out your form electronically, please download the form and open it with Acrobat 7 or later.

How can I access this form?
na
Form (PDF or Word)