Follow the steps to successfully fill out the Geksocom online

1. Click ‘Get Form’ button to access the document and open it for editing.
2. Begin by entering patient information. Fill in the patient's full name, date of birth, social security or identification number, and address details including city, state, and zip code. Provide an area code followed by the phone number.
3. Specify the group name and type of plan associated with the patient.
4. Complete the provider information section. Enter the dentist's name, provider NPI number, and location ID number. Include the provider's address, city, state, zip code, and phone number.
5. Document the name of the previous vendor that issued the original approval, the banding date, the case rate approved, and the amounts paid and owed for dates of service that occurred prior to DentaQuest.
6. Specify the balance expected for future dates of service and the number of adjustments remaining.
7. Review any additional information requirements. If the member is transferring from an existing Medicaid program, provide a copy of the original orthodontic approval. For private pay or transfers from commercial insurance, include original diagnostic photos or OrthoCad equivalent and any optional radiographs.
8. Ensure all sections are completed, and verify the information for accuracy.
9. Submit the completed form to DentaQuest - TennCare via mail or fax as specified in the address provided.
10. Finally, make sure to save the changes, download a copy, print it, or share the form as needed.

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