Form 6504, Prior Authorization for Dental Services

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Effective Date: 7/2010


Updated: 7/2010


To initiate/request prior authorization for dental services and dental sedation.

A treatment plan may be attached in addition to Form 6504. If a treatment plan is attached, this form must still be completed for dental services to be authorized on the Individual Plan of Care (IPC).


When to Prepare

Completion of the form is initiated upon request from the individual indicating a need for dental services. This form is not required for an initial evaluation for treatment that will cost $200 or less.

Number of Copies

One original and copies for all members of the service planning team.


A copy is sent to the dentist and to all other members of the service planning team. The case manager keeps the original in the individual's file. A copy is sent to the Texas Health and Human Services Commission (HHSC), along with a copy of the Individual Plan of Care (IPC) for prior authorization.

Form Retention

Each Deaf Blind with Multiple Disabilities provider agency must keep Form 6504 according to the record retention requirements found in Texas Administrative Code, Chapter 49 (related to contracting for Community Care Services).

Detailed Instructions

Individual Name, Date of Birth, Medicaid No. — The case manager enters the individual's name, date of birth and Medicaid number.

Dentist Name, Address and Telephone No. —The case manager or dentist enters the dentist name, address and telephone number.

Examination and Treatment Record — The dentist completes the Dental Services and Dental Sedation sections of Form 6504.

Dentist Signature, License No. and Date — The dentist must provide the license number and sign and date the form.

DBMD Program Signature and Date — DBMD program staff must sign and date the form.

Approved/Denied/Additional Information — DBMD program staff must check the appropriate box.