Get Orthodontic Expense Worksheet/continual Reimbursement Form

Filling out the Orthodontic Expense Worksheet/Continual Reimbursement Form online can streamline the process of managing your orthodontic expenses. This guide provides clear instructions to help you complete the form correctly and efficiently.

Follow the steps to complete the Orthodontic Expense Worksheet/Continual Reimbursement Form online.

1. Press the ‘Get Form’ button to access the Orthodontic Expense Worksheet/Continual Reimbursement Form and open it in your browser.
2. Enter the plan participant name in the designated field at the top of the form.
3. Provide the name of the person receiving orthodontic services.
4. Input the plan participant's Social Security number carefully.
5. Fill in the participant's employer information.
6. Complete the Orthodontic Expense and Service Schedule by entering the total treatment fee.
7. Specify the expected insurance coverage amount.
8. If applicable, enter the initial payment amount and the date it was paid.
9. If there is no insurance coverage, indicate that by checking ‘No Coverage’.
10. Input the orthotic records/model fee if it is separate from the treatment fee.
11. Specify the patient's monthly payment amount, starting date of monthly payments, and the date it was paid.
12. Indicate the expected number of months in treatment.
13. In the Continual Reimbursement Benefit Election section, fill in the years for the first, second, and third years.
14. For each month, enter the expected reimbursement amount for orthodontia expenses.
15. Sign the document in the space provided as the employee, acknowledging understanding of the reimbursement process.
16. Provide the orthodontist's name and phone number.
17. The orthodontist must sign the form, certifying that the expenses were incurred.
18. Review all filled sections for accuracy and completeness before submitting.
19. Once completed, save your changes, download a copy of the form, print it, or share it as necessary.

Take control of your orthodontic expenses today by completing the Orthodontic Expense Worksheet/Continual Reimbursement Form online.