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ELASTODONTIC/POSITIONED PRESCRIPTION PLEASE PRINT Account # LO B I L L I N G A D D R E S Great Lakes Orthodontics, Ltd. 200 Cooper Avenue, Lawanda, N.Y. 14150 Toll Free: 800-828-7626 PO # (i.e., or
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How to fill out accelero orthodontic form
How to fill out an accelero orthodontic form:
01
Start by gathering all necessary information such as personal details, contact information, and relevant medical history.
02
Ensure that you have the correct form and any additional documents or instructions provided by your orthodontist.
03
Begin by filling out the patient's name, date of birth, and contact information in the designated fields.
04
Provide any relevant details about your dental insurance, including the policy number and any required authorization or referral information.
05
Next, answer any questions related to your medical history, including any allergies, chronic conditions, or medications you are currently taking.
06
Provide information about any previous orthodontic treatment, including the name of your previous orthodontist and the dates of treatment.
07
If you have any specific concerns or preferences regarding your orthodontic treatment, make sure to communicate them clearly in the appropriate section of the form.
08
Carefully read and understand the terms and conditions, as well as any financial agreements, and sign and date the form.
09
Double-check all the information you have provided to ensure its accuracy and completeness before submitting the form to your orthodontist.
Who needs an accelero orthodontic form:
01
Patients who are considering or undergoing orthodontic treatment with the Accelero system may need to fill out an accelero orthodontic form.
02
It is typically required by orthodontists as part of the initial consultation or treatment process to gather essential information about the patient's medical history and treatment preferences.
03
The form may be required for both children and adults seeking orthodontic treatment with the Accelero system.
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What is accelero orthodontic form?
Accelero orthodontic form is a document used to report orthodontic treatment provided to patients.
Who is required to file accelero orthodontic form?
Orthodontists and dental providers are required to file accelero orthodontic form.
How to fill out accelero orthodontic form?
Accelero orthodontic form can be filled out electronically or manually, following the instructions provided on the form.
What is the purpose of accelero orthodontic form?
The purpose of accelero orthodontic form is to track orthodontic treatment provided and ensure accurate reporting and billing.
What information must be reported on accelero orthodontic form?
Information such as patient details, treatment dates, type of treatment, provider information, and billing codes must be reported on accelero orthodontic form.
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