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Source: www.maine.gov
Tags: Orthodontics
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Prior Authorization for Children’s Limited Orthodontic Services (Continued). Please describe your treatment plan below, or attach it to this …

Prior Authorization for Children’s Limited Orthodontic Services
Phone: 1-866-796-2463
MaineCare ID

Fax: 207-287-7643
Member Name: ______________________________________________ DOB: ____________ Sex: Male Female

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Other insurance: Yes No

Parent/Guardian Name(s) (if child): ___________________________________________________________ Home/boarding Hospital/Nursing Facility

Member’s Address: ________________________________________________________________________________ Provider ID

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Provider Name: _________________________________________________

Phone: ____________________________

Provider Address: _________________________________________________________________________________

Fax: ______________________________

All information requested on this form must be legible and complete or form will be returned.

Please check the requested procedure(s):
Limited Orthodontic Treatment Primary Dentition (D8010) Transitional Dentition (D8020) Adolescent Dentition (D8030) Orthodontic Appliances Removable Appliance Therapy (D8210) Fixed Appliance Therapy (D8220) Interceptive Orthodontic Treatment Primary Dentition (D8050) Transitional Dentition (D8060)

Please provide a brief description of the problem:

MaineCare Prior Authorization Form for Limited Orthodontics for Children Revised: 04/15/2009

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