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- Form HCA13-863 "Tooth Chart Form" - Washington
Form HCA13-863 "Tooth Chart Form" - Washington
What Is Form HCA13-863?
This is a legal form that was released by the Washington State Health Care Authority - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.
Form Details:
- Released on February 1, 2015;
- The latest edition provided by the Washington State Health Care Authority;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of Form HCA13-863 by clicking the link below or browse more documents and templates provided by the Washington State Health Care Authority.
Download Form HCA13-863 "Tooth Chart Form" - Washington
![Form HCA13-863 "Tooth Chart Form" - Washington](https://data.templateroller.com/pdf_docs_html/26/260/26092/page_1_thumb.png "Form HCA13-863 "Tooth Chart Form" - Washington")
1DATE
CLIENT’S NAME
Tooth Chart
CLIENT’S ID NUMBER
DENTIST/DENTURIST’S NAME
DENTIST/DENTURIST’S PHONE NUMBER (with Area Code)
PROVIDER NPI NUMBER
PROVIDER FAX NUMBER
Have all dental and periodontal services been completed on all remaining teeth? Yes ____ No ____
If not, please submit treatment plan and periodontal chart.
Mark the chart below
HCA 13-863 (2/15)
DATE
CLIENT’S NAME
Tooth Chart
CLIENT’S ID NUMBER
DENTIST/DENTURIST’S NAME
DENTIST/DENTURIST’S PHONE NUMBER (with Area Code)
PROVIDER NPI NUMBER
PROVIDER FAX NUMBER
Have all dental and periodontal services been completed on all remaining teeth? Yes ____ No ____
If not, please submit treatment plan and periodontal chart.
Mark the chart below
HCA 13-863 (2/15)
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