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Click ‘Get Form’ to open the hca 13 863 in the editor.
Begin by entering the DATE at the top of the form. This is essential for record-keeping.
Fill in the CLIENT’S NAME and CLIENT’S ID NUMBER accurately to ensure proper identification.
Next, provide the DENTIST/DENTURIST’S NAME and their PHONE NUMBER, including area code, for contact purposes.
Input the PROVIDER NPI NUMBER and FAX NUMBER to facilitate communication with insurance providers.
Indicate whether all dental and periodontal services have been completed on all remaining teeth by checking 'Yes' or 'No'. If 'No', attach a treatment plan and periodontal chart as instructed.
Finally, mark the tooth chart below according to your assessment of each tooth's condition.

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Versions	Form popularity	Fillable & printable
2015	4.9 Satisfied (32 Votes)
2014	4.4 Satisfied (125 Votes)

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hca 13 863 form

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