Follow the steps to complete the form online effectively.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin filling out the provider information at the top of the form. Enter the name of the orthodontic provider, their provider number, and the mailing address.
3. Next, fill in the client information section. Provide the client's name, client registration number, mailing address, and date of birth in the specified format (YYYY/MM/DD).
4. Indicate the start date of active orthodontic treatment by filling in the date (YYYY/MM/DD) in the corresponding field.
5. Enter the completion date of active orthodontic treatment in the appropriate field (YYYY/MM/DD) and answer whether the original treatment plan was changed by checking 'YES' or 'NO'. If 'YES', please provide an explanation.
6. State whether the objectives of the treatment plan were accomplished by checking 'YES' or 'NO'. If 'NO', explain why in section (a) and list the services rendered since the initiation of treatment, including dates, in section (b). Attach a separate sheet if necessary.
7. Indicate whether retainers were inserted by selecting 'YES' or 'NO'. If 'NO', please provide an explanation.
8. Fill in the projected duration of the retention phase of orthodontic treatment.
9. Answer whether the client requires additional dental services by selecting 'YES' or 'NO'. If 'YES', provide an explanation.
10. Finally, confirm that all information provided is complete and accurate. The provider should sign the form and include the date (YYYY/MM/DD). After completing the form, you can save changes, download the document, print it, or share it as needed.

Take a moment to complete your forms online to ensure timely processing.