Follow the steps to fill out the form correctly.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Select the applicable type of transaction by checking the appropriate boxes for 'Statement of Actual Services' or 'Request for Predetermination/Preauthorization'.
3. Enter the primary payer information. Include the full name (last, first, middle initial, suffix), address, city, state, and zip code.
4. Indicate the gender of the primary subscriber by selecting 'M' for male or 'F' for female.
5. Provide the subscriber identifier, which can be either the Social Security Number (SSN) or the ID number.
6. Identify the relationship to the primary subscriber by checking the appropriate box (Self, Spouse, Dependent Child, Other).
7. Indicate the student status by selecting full-time student (FTS) or part-time student (PTS).
8. Fill in the patient's information, including their name, address, date of birth, and gender.
9. Document the record of services provided by listing the necessary details in the provided fields, including procedure dates and related tooth information.
10. Complete the missing teeth information by placing an 'X' on each missing tooth on the designated diagram.
11. In the authorizations section, sign to confirm awareness of the treatment plan and associated fees, acknowledging responsibility for charges not covered by insurance.
12. After completing all necessary fields and sections, review your entries for accuracy. Save changes to preserve your information, and prepare to download, print, or share the form as needed.

Complete your documents online today for a hassle-free experience.