TX HHS Form 6504. Prior Authorization for Dental Services

The TX HHS Form 6504, Prior Authorization for Dental Services, is a crucial document used to obtain prior authorization for dental services in the Program Deaf Blind with Multiple Disabilities (DBMD). This form helps solve the problem of ensuring that dental care is authorized before treatment begins. It should be used by case managers and dentists to facilitate the process.

The form requires identifying data, including individual name, date of birth, Medicaid number, city, state, ZIP code, and telephone number. The dentist must complete an examination authorization section, which does not allow for definitive dental care until treatment is authorized. The dentist must also provide a detailed description of the services requested, including tooth numbers, ADA codes, estimated fees, frequency, and service total.

The form has several important sections, including the Examination and Treatment Record, where the dentist indicates one tooth number, procedure, and estimated fee per line. Additionally, there is space for the dentist to describe dental sedation services and indicate if the major dental condition is acute, slowly progressive, or static. The DBMD program staff will review this information to obtain prior authorization of services.