Get Dental Privileges Request Form

Filling out the Dental Privileges Request Form online is a straightforward process designed to ensure that applicants clearly communicate their dental privilege needs. This guide will walk you through each section of the form, offering clear and supportive instructions to help you complete it efficiently.

Follow the steps to fill out the form accurately.

1. Press the ‘Get Form’ button to access the document and open it in your preferred editing tool.
2. Begin by selecting the appropriate privilege level in the 'Requested' column. Options include full, limited, or none. Ensure you check the box that best reflects your request.
3. Proceed to fill out the 'Code' and 'Dental Procedure' sections. Carefully review the list of procedures provided and enter the respective code for each procedure you are requesting.
4. Review each category under dental privileges—diagnostic, preventive, restorative, endodontics, periodontics, prosthodontics, oral surgery, and miscellaneous services. Complete these sections by marking the relevant requests.
5. Once you have filled out all applicable sections and entered all necessary codes and requests, finalize your entries by signing the form. Enter your date alongside your signature.
6. After completing the form, you can save your changes. Take the opportunity to download or print the document for your records. Share it with the appropriate reviewer or board as necessary.

Start completing your Dental Privileges Request Form online today!