SD Medicaid at-risk referral form

Use this form to alert DDSD's Medicaid dental care coordinators of a patient who may benefit from services to support the patient's continued care.

"At-risk" may indicate the Medicaid patient has significant health concerns and is in need of immediate or extensive dental care, has substantial barriers to receiving treatment, or has a history of missed appointments which could lead to being dismissed from the dental practice.

Please complete as much of the form as possible, including any contact information for the patient and parent, guardian, or other caregivers. The information will be provided to our Medicaid Dental Care Coordinators.

If you have any questions about the care coordination process or additional information about the patient, please contact us by email at or by phone at 877-841-1478.