Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Orthodontic Billing Authorization Form
Responsible Party Name
Patient Name *
Treatment Type
Total Treatment Cost
Insurance Coverage Available
Insurance Carrier
Orthodontic Lifetime Maximum
Down Payment Amount
Monthly Payment Amount
Payment Authorization Signature
Date
Orthodontic Billing Authorization Form template from formisoft.com. formisoft.com/intake-templates/orthodontic-billing-authorization