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Orthodontic Billing Authorization Form
Billing

Orthodontic Billing Authorization Form

2 pages•16 fields•HIPAA-ready
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Orthodontic Billing Authorization Form

Orthodontic Billing Authorization Form

Page 1 of 2

Responsible Party Name
Jane Martinez
Patient Name
Jane Martinez
Treatment Type
Select an option...
Total Treatment Cost
0
Insurance Coverage Available
Option A
Option B
Option C
Insurance Carrier
Blue Cross Blue Shield
Orthodontic Lifetime Maximum
0
Down Payment Amount
0
Monthly Payment Amount
0
Payment Authorization Signature
Sign here
Submit
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This orthodontic billing authorization form provides a comprehensive financial agreement template specifically designed for the unique billing requirements of orthodontic practices. Unlike standard dental procedures, orthodontic treatment typically spans 18 to 36 months and requires structured payment plans, making clear financial agreements essential. The form captures detailed insurance benefit information including orthodontic lifetime maximums, coverage percentages, dependent age limits, and whether treatment has already begun under a previous plan. It also documents treatment cost estimates, initial down payments, and monthly payment schedules.

The template includes sections for responsible party designation, multiple payment methods (auto-pay, credit card on file, monthly invoicing), late payment policies, and what happens if treatment is discontinued early. It addresses common orthodontic-specific scenarios like broken bracket fees, lost retainer charges, and costs for extended treatment beyond the initial estimate. The form also includes authorization for insurance claim submission, assignment of benefits, and acknowledgment that the responsible party understands their financial obligation regardless of insurance coverage. This comprehensive approach protects the practice financially while ensuring patients understand all costs associated with achieving their ideal smile.

What's included

  • Responsible party information
  • Patient details and treatment type
  • Total treatment cost breakdown
  • Insurance coverage and benefits
  • Orthodontic lifetime maximum verification
  • Down payment amount
  • Monthly payment schedule
  • Payment method authorization
  • Late payment policy acknowledgment
  • Treatment discontinuation terms
  • Assignment of benefits
  • Financial responsibility agreement

Who uses this template

  • Orthodontic specialty practices
  • General dentistry offices offering orthodontics
  • Pediatric dental practices with orthodontic services
  • Clear aligner provider offices
  • Multi-location orthodontic groups

All form fields

10 fields across 2 pages. Customize any field after signing up.

Responsible Party NameText
Patient NameText
Treatment TypeDropdown
Total Treatment CostNumber
Insurance Coverage AvailableMultiple Choice
Insurance CarrierText
Orthodontic Lifetime MaximumNumber
Down Payment AmountNumber
Monthly Payment AmountNumber
Payment Authorization SignatureE-Signature
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