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Dental HMO Continuing Orthodontic Treatment Request Form 10-22-14 (2)

Dental HMO Continuing Orthodontic Treatment Request Form 10-22-14 (2) 2026

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The document is a request form for continuing orthodontic treatment coverage under SafeGuard Health Plans, Inc. It outlines the eligibility criteria, required documentation, and submission process for subscribers who are currently undergoing active orthodontic treatment. The form must be completed by both the subscriber and the orthodontist, and submitted within thirty days of the plan's effective date to ensure coverage determination.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Subscriber Information section. Enter your name, Social Security Number, address, and contact details accurately.
Next, provide your Company/Organization Name and Previous Dental Carrier information. Ensure all fields are completed to avoid delays.
In the Orthodontist Information section, have your orthodontist fill in their name, contact number, and address. They must also provide their Taxpayer Identification Number.
Complete the financial details including the Initial Treatment Term, amounts paid by you and the prior carrier. This information is crucial for processing your request.
Review all entries for accuracy before submitting. Ensure that Evidence of Payment and Provider Claim Form documentation is attached.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (56 Votes)
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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What reasons will insurance cover braces?

Common Signs That You Might Need Braces Crooked or Crowded Teeth. Difficulty Biting or Chewing. Jaw Pain or Clicking Sounds. Speech Difficulties. Early Loss of Baby Teeth.

What qualifies as medically necessary for braces?

Typically scheduled every four to eight weeks, these appointments involve adjustments to your braces or clear aligners, checking the fit of appliances, and monitoring the movement of your teeth. These visits are essential for ensuring your orthodontic treatment stays on track and achieves the desired results.

How are braces deemed medically necessary?

Breaking down braces coverage Some coverage may be available for adults if braces are considered medically necessary. This can include cases of severe misalignment, overbite or underbite, or jaw abnormalities that cause difficulty with chewing, speech issues, or chronic jaw pain.