1. A. The Maryland Uniform Dental Consultation Referral Form shall read as follows: (SEE NEXT PAGE)

   

2. B. The electronic equivalent of the uniform consultation referral form is as follows:

   Uniform Dental Consultation Referral
   Field	Length	Start	Stop
   1 - Patient last name	18	1	18
   2 - Patient first name	12	19	30
   3 - Patient MI	1	31	31
   4 - Patient DOB	8	32	39
   5 - Patient phone number	10	40	49
   6 - Patient member number	16	50	65
   7 - Patient site number	10	66	75
   8 - Carrier name	24	76	99
   9 - Carrier address 1	24	100	123
   10 -Carrier address 2	24	124	147
   11 - Carrier city	24	148	171
   12 - Carrier state	2	172	173
   13 - Carrier zip code	9	174	182
   14 - Carrier phone number	10	183	192
   15 - Carrier fax number	10	193	202
   16 - Primary/requesting dentist last name	18	203	220
   17 - Primary/requesting dentist first name	12	221	232
   18 - Primary/requesting dentist MI	1	233	233
   19 - Primary/requesting dentist specialty	25	234	258
   20 - Primary/requesting dentist institution/group name	80	259	338
   21 - Primary/requesting dentist NPI #	10	339	348
   22 - Primary/requesting dentist address 1	24	349	372
   23 - Primary/requesting dentist address 2	24	373	396
   24 - Primary/requesting dentist city	24	397	420
   25 - Primary/requesting dentist state	2	421	422
   26 - Primary/requesting dentist zip	9	423	431
   27 - Primary/requesting dentist phone	10	432	441
   28 - Primary/requesting dentist fax	10	442	451
   29 - Specialist dentist last name	18	452	469
   30 - Specialist dentist first name	12	470	481
   31 - Specialist dentist MI	1	482	482
   32 - Specialist dentist specialty	25	483	507
   33 - Specialist dentist institution/group name	80	508	587
   34 - Specialist dentist NPI #	10	588	597
   35 - Specialist dentist address 1	24	598	621
   36 - Specialist dentist address 2	24	622	645
   37 - Specialist dentist city	24	646	669
   38 - Specialist dentist state	2	670	671
   39 - Specialist dentist zip	9	672	680
   40 - Specialist dentist phone	10	681	690
   41 - Specialist dentist fax	10	691	700
   42 - Reasons for referral	80	701	780
   43 - Brief history, dx, results or attachment	120	781	900
   44 - Service desired - code	2	901	902
   45 - Place of service - code	2	903	904
   46 - Teeth diagram - attachment	2	905	906
   47 - Authorization number	10	907	916
   48 - Referral validity date	8	917	924
   49 - Signature/electronic person completing the form	30	925	954
   50 - Authorized signature/electronic	30	955	984
   Referral certification is not a guarantee of payment. Payment of benefits is subject to a member’s eligibility on the date that the service is rendered and to any other contractual provision of the plan/carrier.

Authority: Insurance Article, §§2-109 and 15-120, Annotated Code of Maryland

Effective date: October 21, 1996 (23:21 Md. R. 1467)

Regulation .03 amended as an emergency provision effective January 28, 1997 (24:4 Md. R. 289); adopted permanently effective May 19, 1997 (24:10 Md. R. 710)

Regulation .07 adopted as an emergency provision effective January 28, 1997 (24:4 Md. R. 289); adopted permanently effective May 19, 1997 (24:10 Md. R. 710)

Chapter recodified from COMAR 09.31.23 to COMAR 31.10.12 effective September 7, 1998 (25:18 Md. R. 1439)

Regulation .02B amended effective January 1, 2005 (31:23 Md. R. 1655); January 13, 2011 (38:1 Md. R. 12)

Regulation .03 amended effective January 13, 2011 (38:1 Md. R. 12)

Regulation .03A amended effective January 1, 2005 (31:23 Md. R. 1655)

Regulation .04A amended effective January 1, 2005 (31:23 Md. R. 1655)

Regulation .05 amended effective January 13, 2011 (38:1 Md. R. 12)

Regulation .06 amended effective January 13, 2011 (38:1 Md. R. 12)

Regulation .06D amended effective January 1, 2005 (31:23 Md. R. 1655)

Regulation .07 amended effective January 13, 2011 (38:1 Md. R. 12)

Regulation .08 adopted effective January 1, 2005 (31:23 Md. R. 1655); January 13, 2011 (38:1 Md. R. 12)