Get the free Orthodontic Termination of Care Submission Form

This form is used to submit a request for the termination of orthodontic care for patients, including required member and provider information, as well as details on the treatment and claims.

How to fill out orthodontic termination of care

How to fill out orthodontic termination of care

1. Obtain the orthodontic termination of care form from your orthodontist's office or download it from their website.
2. Fill in the patient's personal information, including their name, date of birth, and contact details.
3. Provide information about the orthodontic treatment received, including the start date and type of treatment.
4. Document any remaining treatment that is necessary or recommended, if applicable.
5. Include a statement indicating the reason for the termination of care, whether it's completion of treatment, patient request, or referral to another provider.
6. Sign and date the form to confirm the termination of care.
7. Submit the completed form to your orthodontist's office for their records.

Who needs orthodontic termination of care?

1. Any patient who has completed their orthodontic treatment and wishes to formally conclude their care.
2. Patients who are transitioning to another orthodontic provider.
3. Clients wishing to document their departure for personal reasons or to prevent future billing.

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What is orthodontic termination of care?

Orthodontic termination of care refers to the formal conclusion of orthodontic treatment for a patient, indicating that the patient no longer requires orthodontic services and that their treatment has been completed.

Who is required to file orthodontic termination of care?

Orthodontic providers, including dentists and orthodontists, are required to file orthodontic termination of care when they conclude treatment for a patient.

How to fill out orthodontic termination of care?

To fill out orthodontic termination of care, providers must complete the designated form with patient details, treatment dates, and the reason for termination, ensuring accuracy and compliance with regulatory guidelines.

What is the purpose of orthodontic termination of care?

The purpose of orthodontic termination of care is to formally document the completion of orthodontic treatment, ensure that all services rendered are accounted for, and provide the opportunity for patients to transition to permanent retention methods.

What information must be reported on orthodontic termination of care?

The information reported must include the patient's name, treatment start and end dates, type of treatment provided, and a summary of the treatment outcome.