Follow the steps to successfully complete the form online:

1. Press the 'Get Form' button to access the form online.
2. Begin by entering the patient's last name in the designated field.
3. Specify if the claim is for themselves or a child by selecting the appropriate option.
4. Fill in the patient’s first name as required.
5. Provide the date of birth for the patient in the format mm/dd/yyyy.
6. Indicate the patient's gender by selecting either 'Male' or 'Female.'
7. Complete the participant information section with last name, first name, middle initial, and social security number.
8. Enter the mailing address, including street, city, state, and ZIP code.
9. List the home and work phone numbers in the specified format.
10. Provide the name of the primary insured and details regarding any other orthodontic plan, if applicable.
11. Complete the spouse or domestic partner’s information section, including name and relevant details.
12. Read and certify the statements, signing and dating where indicated for both the participant and spouse/domestic partner.
13. Fill out the orthodontic treatment and charges section to be completed by the orthodontist.
14. Ensure all necessary documents, such as intraoral photographs and X-rays, accompany the claim form.
15. Once you have completed the form, save your changes, download a copy, print it, or share it as needed.

Complete your documents online effortlessly.