Form 13-863 - hca wa: Fill out & sign online

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Click ‘Get Form’ to open it 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 the area code, for any necessary follow-up.
Input the PROVIDER NPI NUMBER and FAX NUMBER to facilitate communication with healthcare providers.
Indicate whether all dental and periodontal services have been completed on all remaining teeth by checking 'Yes' or 'No'. If 'No', be sure to submit a treatment plan and periodontal chart as instructed.
Finally, mark the chart below as required, ensuring all information is clear and legible before submission.

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