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*THIS FORM MUST BE SIGNED PRIOR TO TOOTH EXTRACTIONSVisadent, l.l.c.
1033 Clifton Avenue
Clifton, New Jersey 07013
Phone: 201 7854146
Fax: 2014857291
CONSENT FORM
AUTHORITY TO OPERATE/TOOTH EXTRACTIONS
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Vis-a-dent l is a form used for reporting information related to dental services and benefits provided to patients.
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Dental providers and organizations that provided services and benefits to patients are required to file vis-a-dent l.
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To fill out vis-a-dent l, providers need to enter patient information, details of services rendered, and other required data in the designated fields on the form.
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The purpose of vis-a-dent l is to ensure accurate reporting of dental services for insurance reimbursement and compliance with regulations.
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Information that must be reported includes patient demographics, service dates, type of services rendered, and provider details.
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