Get the free Dental HMO Continuing Orthodontic Treatment Request Form 10-22-14 (2)
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Metropolitan Life Insurance Company MetLife Health Plans, Inc. Safeguard Health Plans, Inc. Dental HMO Continuing Orthodontic Treatment Request Form If you or one of your enrolled dependents is currently
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How to fill out dental hmo continuing orthodontic
How to fill out MetLife Dental HMO Continuing Orthodontic Treatment Request
01
Obtain the MetLife Dental HMO Continuing Orthodontic Treatment Request form.
02
Fill in the patient's personal information including name, address, and date of birth.
03
Provide the orthodontist's details, including their name, practice address, and contact information.
04
Write the case number or member ID as indicated on any previous orthodontic treatment documents.
05
Indicate the type of orthodontic treatment previously received and the dates of service.
06
Attach any required documentation, such as treatment plans or progress notes from the orthodontist.
07
Sign and date the form to confirm that all provided information is accurate.
08
Submit the completed form to MetLife according to the instructions provided on the form.
Who needs MetLife Dental HMO Continuing Orthodontic Treatment Request?
01
Patients currently undergoing orthodontic treatment under the MetLife Dental HMO plan who wish to continue their treatment.
02
Orthodontists who need to provide documentation for their patients seeking continued coverage.
03
Individuals looking to transition their orthodontic treatment details for insurance processing.
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What is MetLife Dental HMO Continuing Orthodontic Treatment Request?
MetLife Dental HMO Continuing Orthodontic Treatment Request is a formal document that orthodontists submit to MetLife to seek authorization for ongoing orthodontic treatment for patients enrolled in the MetLife Dental HMO plan.
Who is required to file MetLife Dental HMO Continuing Orthodontic Treatment Request?
The orthodontist or dental care provider who is providing the ongoing orthodontic treatment is required to file the MetLife Dental HMO Continuing Orthodontic Treatment Request on behalf of the patient.
How to fill out MetLife Dental HMO Continuing Orthodontic Treatment Request?
To fill out the MetLife Dental HMO Continuing Orthodontic Treatment Request, the dental care provider must complete the form with patient information, treatment details, and any necessary clinical information that supports the need for continuation of treatment.
What is the purpose of MetLife Dental HMO Continuing Orthodontic Treatment Request?
The purpose of the MetLife Dental HMO Continuing Orthodontic Treatment Request is to obtain pre-authorization and ensure that continued orthodontic treatment is covered under the patient's dental insurance plan.
What information must be reported on MetLife Dental HMO Continuing Orthodontic Treatment Request?
The information that must be reported includes the patient's personal details, treatment history, current treatment plan, expected duration of treatment, and any relevant clinical notes from the orthodontic provider.
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