Get Dental Pre-authorisation Request Form

This guide provides essential steps for users to efficiently complete the Dental Pre-authorisation Request Form online. Following these instructions will help ensure that your request is submitted accurately and promptly.

Follow the steps to complete the form successfully.

1. Click 'Get Form' button to obtain the form and open it in your online editor.
2. Begin by entering the clinic or hospital name in the designated field. Include the contact number for easy communication.
3. Fill in the date when you are completing the form. This helps with the timely processing of your request.
4. Provide the dentist's name and contact number to facilitate any follow-up regarding the treatment.
5. Indicate the total number of pages being submitted with the form.
6. In the Administrative section, enter your membership number and the group or company name as appropriate.
7. Fill in the patient's date of birth and select the appropriate gender from the options provided.
8. Complete the patient’s name and include the policy or group number and plan information.
9. Provide the patient's phone number for contact regarding the pre-authorisation.
10. In the Dentist's section, specify the duration of the illness, chief complaint, and main symptoms.
11. Indicate the diagnosis and any other relevant conditions the patient may have.
12. Tick the appropriate boxes according to the type of procedure required, such as routine dentistry or orthodontics.
13. List the recommended investigations or procedures, using the appropriate tooth number as shown on the Teeth Map.
14. Detail the service code, description, tooth number or letter, and the cost associated with each service.
15. In the Medical practitioner declaration section, the dentist must certify the accuracy of the information provided by signing and stamping the document.
16. Review the AXA response section once the approval is received. This will include the approval number and any comments.
17. Save changes to the form, then download, print, or share the form as necessary for submission.

Complete your Dental Pre-authorisation Request Form online today for a streamlined healthcare experience.