Katrina M. Sanders RDH, BSDH, M.Ed, RF

Reference Documents

 

The documents below are intended to be used as templates and/or resources for improved efficiency within the dental practice.

Template for SRP Claim Appeal

This template is to be utilized for rejected or denied scaling and root planing therapy.  Be sure to complete all required fields prior to submittal.

 

Template for SRP Clinical Note Narrative

This template is to be utilized as a clinical note narrative for patients diagnosed with and treated for active periodontal conditions. Be sure to complete all required fields prior to signing your clinical note. 

 

Template for Informed Refusal for Periodontal Therapy

This template is to be utilized for instances in which patients refuse periodontal therapy.  Please review your state and licensure policies regarding legalities of informed refusal of services.  This form is intended to support the dental professional but is not a replacement for professional responsibility to patient care.

 

Template for Informed Refusal for Dental Radiographs

This template is to be utilized for instances in which patients refuse diagnostic radiographs.  Please review your state and licensure policies regarding legalities of informed refusal of services.  This form is intended to support the dental professional but is not a replacement for professional responsibility to patient care.