New Dental Specialty Referral Request Form!

Health Choice Arizona is pleased to announce we're going interactive! HCA has turned the Dental Specialty Referral Form into an easy to use, interactive format.

Simply open the "pdf" form and type in the required information. Print a copy of the completed form and fax to 480-350-2217. Don't forget to fax your chart notes with pediatric dentist referrals.

When x-rays are required (third molar extractions and endodontic retreats), print the form, attach the x-rays and other required documents and mail to:

• Health Choice Arizona, Inc.
• Attn: Dental Services Department
• 410 N. 44th Street, Ste. 520
• Phoenix, AZ 85008

Check this page often, more interactive forms - such as the Dentist Credentialing and Re-credentialing Forms - will be posted to the HCA Web site soon!

Dental Specialty Referral Form