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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 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 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 Health Care Authority.
![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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Most popular documents
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DA Form 2062 "Hand Receipt/Annex Number"
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DD Form 2977 "Deliberate Risk Assessment Worksheet"
-
DA Form 31 "Request and Authority for Leave"
-
"Zappos Kid Shoe Size Chart"
-
DD Form 2813
-
"Vsepr Theory (Molecular Shapes) Chart"
-
DD Form 1750 "Packing List"
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DA Form 3595 "Record Fire Scorecard"
-
AF Form 910 "Enlisted Performance Report (AB Thru Tsgt)"
-
DD Form 2923 "Privacy Act Data Cover Sheet"
Popular Articles
- 2020 Tax Deductions for Homeowners 2020 Tax Deductions for Homeowners
- How to Convert Personal Use Property to Business Use? How to Convert Personal Use Property to Business Use?
- How to Rent Your First Apartment? How to Rent Your First Apartment?
- How To Buy a House in the United States? How To Buy a House in the United States?
- Washington State Patrol Inspection Request Form Washington State Patrol Inspection Request Form
- USCIS Form I-551, Permanent Resident Card USCIS Form I-551, Permanent Resident Card
- Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration
- USCIS Form I-797C, Notice of Action USCIS Form I-797C, Notice of Action
