Get Comprehensive Orthodontic Treatment Prior Authorization Request Form

Filling out the Comprehensive Orthodontic Treatment Prior Authorization Request Form online can be straightforward when you follow the proper steps. This guide will provide you with detailed instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to complete your prior authorization request form.

1. Click ‘Get Form’ button to access the request form and open it in your preferred editing tool.
2. Begin by filling out the patient information section. Enter the patient's name, date of birth, age, and address. Also, include the names of the parent(s) and the patient's Medicaid I.D. number.
3. Provide details about the referring dentist and indicate whether preventive and restorative treatment has been completed by selecting 'Yes' or 'No'.
4. Assess the patient's oral hygiene by checking the appropriate box for 'Good', 'Fair', or 'Poor'.
5. Fill in the diagnosis section. Specify the type of dentition (Primary, Transitional, Adolescent, or Adult) and check the correct Angle Class (I, II, or III).
6. Measure and enter the overbite and overjet in millimeters. Then, provide details about crowding in both the maxillary and mandibular arches.
7. In the diagnostic treatment criteria section, check all applicable major and minor criteria. Be aware that options A and B cannot appear on the same arch.
8. If the patient does not meet the criteria, describe any other functional impairment in the space provided and attach relevant documentation.
9. Complete the special medical consideration section if applicable, and attach written documentation as required.
10. Select the proposed treatment option by checking the appropriate box for comprehensive orthodontic treatment. Specify whether it is for a single arch or both arches.
11. Fill out the additional information section, including estimated time, requested fee, date submitted, office contact number, and provider name/practice name.
12. Lastly, certify the accuracy of the examination by providing your signature in the designated area.

Complete your Comprehensive Orthodontic Treatment Prior Authorization Request Form online today for a smooth submission process.