Dental

ADA Dental Claim Form Instructions

Follow the instructions to fill out the American Dental Association’s (ADA) dental claim form.

CareSource TMD Screening Examination Form

Use this screening form to determine evidence of a temporomandibular disorder (TMD) in a patient.

Dental EFT Enrollment Authorization Agreement Form

Follow the instructions to enroll in Scion Dental’s EFT program.

Evaluation Form for Comprehensive Orthodontic Treatment

Use this form to evaluate a patient for comprehensive orthodontic treatment options.

Evaluation Form to Scaling and Root Planning

Use this form to evaluate scaling and root planning.

ODJFS Dental Services Prior Authorization Form

Submit this form to the Ohio Department of Job and Family Services (ODJFS) to request prior authorization for dental services.

Orthodontic Confirmation of Care Form

Submit this form to notify CareSource that a referred patient is not a candidate for comprehensive orthodontic treatment.

Orthodontic Continuation of Care Form

Submit this form to request continuation of care for orthodontic services.

Orthodontic Evaluation and Predetermination Form

Submit this form to request prior authorization for orthodontic services.

Orthodontic Form for Non-Compliance/Termination with Comprehensive or Interceptive Orthodontic Treatment

Submit this form to notify CareSource of a patient’s noncompliance/termination during orthodontic treatment.

Orthodontic Treatment Plan Acknowledgements Form for Comprehensive Orthodontic Treatment

Submit this form along with a prior authorization request to acknowledge a comprehensive treatment plan for a dental patient.