TX HHS Form 3108. Dental Report

The TX HHS Form 3108, Dental Report, is a crucial tool for healthcare professionals to document dental examination and treatment records. This form helps counselors determine the necessary treatment needs for individuals with reported disabilities, ensuring that patients receive the appropriate care.

This report requires essential information such as patient details (date of birth, social security number), reported disability, reason for referral, and examination and treatment records. The dentist must complete all applicable items using the charting system shown, including one tooth number, one procedure, and one estimated fee per line. Additionally, the form specifies that only three teeth can be listed as missing or replaced.

The TX HHS Form 3108 is typically used in situations where patients require dental care for reported disabilities. The dentist's responsibility is to complete the examination and treatment record, ensuring that all necessary information is provided for treatment authorization. Key points to note include:

• Required patient information: date of birth, social security number, telephone number
• Reported disability and reason for referral must be documented
• Examination and treatment records must be completed using the charting system shown
• Only three teeth can be listed as missing or replaced