Orthodontic Claim Form . pdf - CFAO - cfao 2026

1. Click ‘Get Form’ to open the Orthodontic Claim Form in our editor.
2. Begin by entering the Carpenter's name, including first, middle, and last names, along with their address.
3. Input the Carpenter's Social Security Number for identification purposes.
4. Fill in the Patient's name and birthdate. Ensure that you indicate the relationship of the patient to the carpenter, as coverage is limited to dependent children.
5. Provide details about the dentist, including their name, license number, mailing address, and Social Security or IRS Taxpayer number.
6. Answer whether the patient is covered by another group dental plan and provide additional information if applicable.
7. Indicate if treatment was a result of an accident and provide relevant dates if necessary.
8. Complete sections regarding prior orthodontic treatment and estimated months of treatment required.
9. List services provided along with corresponding fees. Be sure to identify missing teeth and specify any unusual services in remarks.
10. Finally, sign and date the form at the bottom where indicated for both the dentist and carpenter or spouse.

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