Missed appointments and dismissal notification form

Missed appointments: Oregon Administrative Rule 410-141-0080(2) (a) (A) (i)

The office policy for missed appointments should be provided to each patient.

Dismissals: Oregon Administrative Rule 410-141-3810 (4)©

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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