Maryland requires a uniform referral form when a primary or requesting dentist refers a dental HMO or plan member to a specialist dentist for consultation, under COMAR 31.10.12. General dentists meet it whenever a patient needs a specialist's consultation or procedure under plan rules. The form records the reason for referral, history and test results, the services desired and how long the referral stays valid.
The primary or requesting dentist completes the patient, carrier, referring dentist, specialist and referral sections and signs. A second, authorizing signature is added only when required.
Download the current version from the source each time; forms change without notice.
Maryland Uniform Dental Consultation Referral Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
When a primary or requesting dentist refers a member of a dental HMO or plan to a specialist dentist for consultation. COMAR 31.10.12 sets the uniform form, so Maryland carriers receive referrals in one layout, with the specialist's details, reason for referral and services desired.
The form has a Referral Is Valid Until date that the referring office fills in according to the carrier's instructions, next to any required authorization number. The form sets no fixed period itself, so the carrier or plan manual governs how long a referral lasts.