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Medi-Cal Oral Health Information Form

Please check the answers that apply to you. Complete one form for each person in your family who is enrolled in Health Net. If you have questions, please call Health Net toll-free at 1-833-493-0428. A representative is available to speak with you Monday through Friday, between 8:00 am and 5:00 pm. TDD/TTY users should dial 1-800-466-7566.

1. Has it been more than 12 months since your last dental visit?*
2. Do you have pain when eating cold, hot, or sugary foods?*
3. Do you have a painful tooth eruption?*
4. Do you have an infected tooth or teeth?*
5. Do you have a broken tooth or teeth?*
6. Is your mouth dry?*
7. Do your gums bleed with you brush or floss?*
8. Have you had any gum (periodontal) treatments?*
9. Do you wear dentures or partials?*
10. Are you currently receiving radiation or chemotherapy?*
11. Are you pregnant?*
12. Do you see a doctor regularly for a chronic medical condition?*
13. Do you have or associate yourself with a mental or physical disability?*

If you think you need to see a dentist before Health Net contacts you, please contact your dental office or seek care from a hospital.

I understand that this information will be disclosed to my new dental plan*