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.

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Download Form HCA13-863 "Tooth Chart Form" - Washington

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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)
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)