Client Treatment History
(For Nevada Medicaid and Nevada Check Up Orthodontic Treatment)
Purpose/Procedure
1. A dentist must complete and submit this report to the orthodontist when referring a Nevada Medicaid
or Nevada Check Up recipient for orthodontic treatment.
2. The orthodontist must submit this report to ewlett ackard
with a prior authorization
request for orthodontia services.
3. The treating orthodontist must complete and submit a new Client Treatment History when requesting
prior authorization for a second phase of orthodontic treatment.
Limitations
Nevada Medicaid and Nevada Check Up consider orthodontic prior authorization requests when this form
shows the eligible recipient is under age 21, received treatment from the treating dentist’s office on at
least two occasions and missed no more than 30% of scheduled appointments.
In addition, the orthodontist to perform the treatment must be enrolled with Hewlett Packard Enterprise
as a Nevada Medicaid provider.
Client Information
Client Name: _________________________________________ Date of Birth: ____________________
Is the client eligible for Nevada Medicaid or Nevada Check Up benefits?
Yes
No
Treatment History
Complete all blanks to describe your treatment experience with this client.
Date of the client’s first treatment visit with your office: _______________________________________
Date of the client’s last treatment visit with your office: ________________________________________
Number of appointments scheduled with your office (drop-in practices write “N/A” here): ____________
Number of missed appointments (drop-in practices write “N/A” here): ____________________________
Reason you believe this client will benefit from orthodontic treatment:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Treating Dentist’s Name (print): ________________________________ Phone: ________________
Treating Dentist’s Signature: ______________________________________ Date: _______________
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