Orthodontic Billing Authorization Form
Form preview
Orthodontic Billing Authorization Form
Page 1 of 2
Sign up and start customizing in minutes.
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.
How to use the Orthodontic Billing Authorization Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Orthodontic Billing Authorization Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Orthodontic Billing Authorization Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 16 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Orthodontic Billing Authorization Form HIPAA compliant?
Yes. All Formisoft templates, including the Orthodontic Billing Authorization Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Orthodontic Billing Authorization Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Orthodontic Billing Authorization Form for your practice. Set up in minutes.
Related templates
Orthodontic Treatment Consent Form
An informed consent form for orthodontic treatment including braces, aligners, and retainers, covering treatment duration, risks, and patient responsibilities.
Dental Implant Billing Authorization Form
Comprehensive billing authorization form for dental implant procedures. Captures treatment plan details, cost breakdown, insurance coverage verification, payment arrangements, and financial responsibility acknowledgment for single or multiple implant placements including bone grafting and restoration phases.
Oral Surgery Billing Authorization Form
Comprehensive billing authorization form for oral and maxillofacial surgery practices. Captures insurance details, financial responsibility acknowledgment, and payment arrangements for surgical procedures including extractions, implants, and reconstructive surgeries.