Missed appointments notification form

Oregon Administrative Rule 410-141-0080(2) (a) (A) (i)
Missed appointments: The number of missed appointments is to be established by the provider or PHP. The number must be the same for commercial members or patients. The provider must document they have attempted to determine the reason(s) for the missed appointments and to assist the OHP member in receiving services.

Fax this form if applicable, and any necessary dismissal attachments to ODS Community Dental, to:
Attn: OHP Dental Coordinator at 503-952-5259 after each missed appointment.

Dental Provider Correspondence Request

Member Information

Member ID #

Member Name

Last name

Provider information

Dentist first name

Dentist last name

Office phone number

Office fax number

Street address

City

State

Zip

Missed appointment report

Date of missed appt

Reason for missed appointment

Your attempts to assist the member:

Rescheduled appointment

Referred for help with transportation

Dismissed, referred to ODS to find another dentist

Other

Dismissal due to missed appt

Attach copies of the following forms:

a) Your office dismissal for missed appointments policy (signed by the Member)

Choose file Please select a gif, pdf, txt, docx, png, or jpg file no larger than 10 Mb

b) Your dismissal letter to the Member

Choose file Please select a gif, pdf, txt, docx, png, or jpg file no larger than 10 Mb

Note: If more than one person missed the appointment, please complete a separate form for that person.

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