Get the free Automatic Orthodontia Request Form - ohr gatech

This form is to be completed for any participant that wants to receive automatic reimbursement for orthodontia expenses. It includes sections for participant information, orthodontia information,

How to fill out automatic orthodontia request form

How to fill out Automatic Orthodontia Request Form

1. Obtain the Automatic Orthodontia Request Form from your dental office or orthodontist's website.
2. Fill in your personal information including your name, address, date of birth, and contact details.
3. Provide your insurance information, including the name of your insurance provider and your policy number.
4. Indicate the reason for the orthodontic request, including any specific concerns or recommendations from your dentist.
5. If applicable, include any relevant medical history or previous orthodontic treatments.
6. Attach any required documentation, such as dental X-rays or treatment plans, as specified by the form.
7. Review the completed form for accuracy and ensure all necessary fields are filled out.
8. Submit the form according to the instructions provided, either by mail, email, or in person.

Who needs Automatic Orthodontia Request Form?

1. Patients referred for orthodontic treatment by their general dentist.
2. Individuals seeking coverage or authorization for orthodontic care from their insurance providers.
3. Parents or guardians filling out the form on behalf of minors in need of orthodontic treatment.

For pdfFiller’s FAQs

What is Automatic Orthodontia Request Form?

The Automatic Orthodontia Request Form is a document used by dental professionals to request authorization for orthodontic treatments on behalf of their patients.

Who is required to file Automatic Orthodontia Request Form?

Dental professionals, specifically orthodontists, who are providing orthodontic care to patients, are required to file the Automatic Orthodontia Request Form.

How to fill out Automatic Orthodontia Request Form?

To fill out the Automatic Orthodontia Request Form, the dental professional must provide patient information, treatment details, and any necessary clinical documentation to support the request.

What is the purpose of Automatic Orthodontia Request Form?

The purpose of the Automatic Orthodontia Request Form is to ensure that the proposed orthodontic treatment is reviewed and approved for coverage by insurance providers.

What information must be reported on Automatic Orthodontia Request Form?

The information that must be reported on the Automatic Orthodontia Request Form includes patient demographics, treatment diagnosis, proposed treatment plan, and supporting clinical evidence or radiographs.