Sec. 31.10.12.08. Uniform Consultation Referral Form — Required Forms

A. The Maryland Uniform Dental Consultation Referral Form shall read as follows:

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.