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Dental HMO Continuing Orthodontic Treatment Request Form Rebranded Version 1-11-19 (2) docx

Dental HMO Continuing Orthodontic Treatment Request Form Rebranded Version 1-11-19 (2) docx 2026

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4.8 out of 5

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The document is a request form for Continuing Orthodontic Treatment under the MetLife Health Plans and SafeGuard Health Plans. It outlines eligibility criteria for coverage, required documentation, and submission guidelines for subscribers currently undergoing orthodontic treatment prior to their coverage start date. The form must be completed by both the subscriber and their orthodontist, and submitted within 30 days of the plan's effective date to ensure timely processing.

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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.
Provide the Company/Organization Name and Previous Dental Carrier information as required.
In the Orthodontist Information section, have your orthodontist complete their details including name, contact number, and address.
Ensure that all financial details such as Initial Treatment Term, Total Ortho Case amount, and payments made are filled in correctly.
Review the form for completeness. Make sure both sections are filled out and all required documentation is attached before submission.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (56 Votes)
2014	4 Satisfied (56 Votes)

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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 is the ADA code for orthodontic visit?

CODE DEFINITION D8660 Pre-orthodontic treatment visit D8670 Periodic orthodontic treatment visit (as part of contract) D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)).

What is the ADA code for orthodontic consultation?

Dental Code D8660: Pre-Orthodontic Examination for Growth.

What is the dental code for continuation of care?

Services billed with CDT D0150 (comprehensive oral evaluation - new or established patient), D0145 (oral evaluation for a patient under three years of age and counseling with primary caregiver), and D0120 (periodic oral evaluation - established patient) for dental exam/evaluation will count towards a continuity of care