Follow the steps to complete the form effectively

1. Click ‘Get Form’ button to access the document and open it in the editing interface.
2. Begin by entering the patient name in the designated field. This should reflect the individual receiving the dental services.
3. Fill in the Member (Medicaid) ID. Ensure this number is accurate as it links to the patient's insurance details.
4. Provide the guarantor name, which is the individual responsible for paying for the services rendered.
5. Indicate the relationship to the patient, such as ‘parent’, ‘guardian’, or ‘partner’, to clarify the connection.
6. List the non-covered services provided along with the corresponding codes and descriptions. Ensure the entries match the recommended services as outlined.
7. Acknowledge the understanding of financial responsibility for non-covered services by providing your signature in the designated area.
8. Date your signature in the space provided to indicate the date of agreement.
9. Complete the guarantor address section, ensuring that the street address, city, state, and zip code are accurate.
10. Fill in the guarantor phone numbers, including home, cell, and work numbers, each in their designated field.
11. Once all fields are complete, review the form for accuracy. Save your changes, and if needed, download, print, or share the completed form.

Complete your Dentaquest Non Covered Services Form online to ensure prompt processing of your dental services.