Transcription of Orthodontic information for authorizations - Wa
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Orthodontic information for authorizations - Wa
Page 1 of 5 HCA 13-666 (1/22) Orthodontic information Orthodontic AuthorizationsIGeneral informationProvider name Performing provider number Billing provider numberPatient s Last name Patient s first name Patient s middle initialPatient s birth date Patient s age (years/months) Client's ID II Orthodontic treatment requested and diagnostic informationPlease check the box for the requested Orthodontic treatment below. Comprehensive treatment Limited treatment Case study only (ETR Requests only) Fixed appliance therapy Extension request (if checked, indicate months required to complete treatment): Transfer case (if checked, indicate months required to complete treatment): Tentative treatment plan:Functional concerns:Will the client require orthognathic surgery? Yes NoHas the client seen a general dentist in the last 12 months? Yes NoStage of dentition: Primary Adolescent Mixed/TransitionalAnterior teethOverjet mmOverbite mmOpen bite mmMidline mmCrossbite Indicate maxillary teeth involvedPosterior teethAngle ClassificationSkeletal classification (check one) Class I Class II Class IIID ental classification (check one)Left Right Class I Class I E to E E to E Class II Class II Class III Class IIIC rossbite Indicate maxillary teeth involvedAnterior Crowding (Approximate)MAX m
Orthodontic treatment requested and diagnostic information Please check the box for the requested orthodontic treatment below. Comprehensive treatment Limited treatment. Case study only (ETR Requests only) Fixed appliance therapy. Extension request (if checked, indicate months required to complete treatment):
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