Members

Below are materials about your benefit and the importance of routine dental check-ups.

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Forms

Conlan Packet

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Payee Data Record Form-STD 204 (English)

Medi-Cal Dental Complaint Form

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Request Personal Health Information from Medi-Cal Dental

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Notice of Improper Billing and Cover Letter

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Notice of Medi-Cal Dental Action

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Medi-Cal Dental Program Authorized Representative Standard Agreement for Organizations Form

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Medi-Cal Dental Program Appointment of Authorized Representative Form

English

Medi-Cal Adult Dental Information

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Notice of Privacy Practices

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