Revised Orthodontic Information form (13-666)

Provider Alert! 

This is a reminder to now use the new version of the Orthodontic Information form (13-666) dated August 2015.

The form can be found on the Washington Apple Health’s Medicaid Forms web page at: http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx.

Beginning January 1, 2016, and after, only the new version of the form will be accepted with authorization requests.

Older versions of the form will be returned to the provider and not processed.