General anesthesia request for dental treatment

Attachment of treatment plan, chart notes and x-rays (if available) are required for review. Chart notes must include what other methods of sedation were attempted but not successful. Submission of this request without documentation will result in processing delays. Attach all files using the ATTACH FILES feature at bottom of form. All services are subject to eligibility and plan provisions in effect at the time services are rendered.

Financial Waiver: Please make sure you use the patient responsibility waiver form provided by the Oregon Health Authority as your client agreement to pay for health services not covered by the Oregon Health Plan. Get the patient responsibility waiver here.