Forms & publications

Notice: If you are looking for Apple Health (Medicaid) client forms and publications, please visit our Free or low-cost forms library.

Agreement of Acceptance (partial denture)

13-965

Complete this form when provisioning all partial dentures.

Form

Dental tooth, arch, and quad numbering

70-351

Instructions on dental tooth, arch, and quad numbering.

Publication

Denture agreement of acceptance

13-809

Denture agreement of acceptance form which must be completed upon date of delivery.

Form

Denture/partial appliance request

13-788

For skilled nursing facilities clients.

Form

Oral Health Connections patient attestation

13-0031

Complete this form with your patients for dental services provided by Oral Health Connections.

Form

Orthodontic discontinuation of service form

13-0039

This form is used to discontinue orthodontic coverage for Apple Health (Medicaid) clients

Form

Orthodontic information authorization form

13-666

Use this form prior to treatment for orthodontic services.

Form

Tooth chart

13-863

Use this chart to indicated where treatment is required.

Form