Forms & publications
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Agreement of Acceptance (partial denture)
13-965Complete this form when provisioning all partial dentures.
FormDental tooth, arch, and quad numbering
70-351Instructions on dental tooth, arch, and quad numbering.
PublicationDenture agreement of acceptance
13-809Denture agreement of acceptance form which must be completed upon date of delivery.
FormDenture/partial appliance request
13-788For skilled nursing facilities clients.
FormOral Health Connections patient attestation
13-0031Complete this form with your patients for dental services provided by Oral Health Connections.
FormOrthodontic discontinuation of service form
13-0039This form is used to discontinue orthodontic coverage for Apple Health (Medicaid) clients
FormOrthodontic information authorization form
13-666Use this form prior to treatment for orthodontic services.
FormTooth chart
13-863Use this chart to indicated where treatment is required.
Form