Get Ga Deltacare Frm 0021 2015-2025

The GA DeltaCare FRM 0021 is a patient encounter form used for documenting dental services. This guide provides detailed instructions to help users complete the form accurately and efficiently online.

Follow the steps to fill out the GA DeltaCare FRM 0021 online

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by filling in the primary enrollee's last name, first name, and middle initial in the respective fields.
3. Enter the treatment date, group number, and facility number, ensuring all details match your records.
4. Provide the primary enrollee ID and facility name, along with the facility address.
5. Indicate whether the patient is self, a spouse, or a child by checking the appropriate box.
6. Fill in the patient's name and date of birth accurately.
7. In the service section, list each procedure performed by entering the procedure code, service description, relevant tooth number, and surface details.
8. Document the relevant charges for each service in the corresponding field, using one line per procedure.
9. Ensure all procedures for the visit are recorded on the form. If multiple services were provided, use blank lines for additional procedures.
10. Include any benefit plan copayments in the designated column. Leave blank if no charge applies.
11. Review all entries for completeness and clarity. Verify that all necessary information has been included.
12. Once completed, save your changes, then you can download, print, or share the form as needed.

Complete your documents online with confidence and accuracy.