Early termination of orthodontic treatment letter, Sign, print, and download this PDF at PrintFriendly

Early termination of orthodontic treatment letter, Sign, print, and download this PDF at PrintFriendly. The Treating orthodontist may bill the member/parent/guardian directly for all services provided after the termination date or another payer if coverage is obtained. Consequences of premature discontinuation of orthodontic treatment are difficult to predict. S. It includes sections for recipient information, reasons for termination, details about retainers, and provider information. , M. D. HealthLeaders offers health care news and solutions for business executives in hospitals and health systems. . By following these steps, you can ensure that your form is filled out accurately and submitted appropriately. The form must be returned to the EDS Prior Approval Unit and outlines potential refund requirements if applicable. The document is a termination request form for orthodontic treatment under the North Carolina Medicaid Program. I am withdrawing from further orthodontic care to above named patient due to lack of patient cooperation (frequent & prolonged missed appointments). M. We would like to show you a description here but the site won’t allow us. It may cause no harm at all, or may result in premature wear of the teeth and or jaw dysfunction and discomfort, aside from any cosmetic shortcomings. This letter is to inform you that as of above Termination of Treatment Date, Won-Woo Park, D. View the Early Discontinuation of Orthodontic Treatment Form in our collection of PDFs. How to fill out the Discontinuation Of Orthodontic Treatment Form online This guide provides clear and supportive instructions on how to complete the Discontinuation Of Orthodontic Treatment Form online. Whatever method you like to sign your early termination of orthodontic treatment letter in DocHub, your eSignature will be legally binding and court-admissible. _________________. of OoLi Orthodontics will be terminating orthodontic care of above named patient. RELEASE AND WAIVER (Premature Removal of Appliances) hereby certify, on behalf of (myself) (my child), and all those who may now or in the future have any interest in the care and treatment of (myself) (my child), that I have, on my own volition and as my voluntary act, requested removal of my orthodontic appliances by Dr. Treatment complications and other extenuating circumstances require removal of orthodontic appliances as soon as possible This case is incomplete and the patient/parent/guardian understands the reason for the discontinuation of treatment. Stay informed—find out more today! An Early Termination of Orthodontic Treatment Letter is a process that involves the use of braces, retainers, and other devices to straighten and align teeth.


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