Orthodontic endorsement form to be completed by a specialist in orthodontics



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THIS FORM TO BE ATTACHED TO THE ATTENDING DENTIST'S STATEMENT OR OTHER CLAIM FORMS



ORTHODONTIC ENDORSEMENT FORM

TO BE COMPLETED BY A SPECIALIST IN ORTHODONTICS


Date:      


Patient Name:      

Employee/Subscriber Name:      

Insured's S.S.N/S.I.N:      

Name of Group Dental Program:      



DESCRIPTION OF SERVICE
Narrative Description      
Starting Date of Treatment      




PROCEDURE

NUMBER


FEE

FOR ADMINISTRATIVE USE ONLY

EXAMINATION

     

$     




























DIAGNOSIS

     

$     




























INITIAL PAYMENT

     

$     




























MONTHLY

     

$     




























QUARTERLY

     

$     




























OTHER PAYMENT

PLAN PLAN:

     

$     



















TOTAL FEE

CHARGED

$     







MAX. ALLOWABLE

$     







DEDUCTIBLE

$     







CARRIER %

$     







CARRIER PAYS

$     







PATIENT PAYS

$     




Orthodontist's Signature: __________________________________________________________ Date: __________________________

FORM RECOMMENDED BY THE COUNCIL ON ORTHODONTIC HEALTH CARE


© American Association of Orthodontists 1999

Endorsement Form 5/00



Reviewed 1/10



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