Updated Denture or Partial Agreement (HCA 13-809) Form

HCA Apple Health


Effective for dates of service on and after August 1, 2016, providers must use the updated Denture or Partial Agreement (HCA 13-809) form. This form has been updated and is now titled Denture Agreement of Acceptance. The new form has two sections:

  • Section 1, Wax Try-In
  • Section 2, Delivery and Seating of Denture(s)

Providers must review both sections with the client and obtain signatures from the client at the wax try-in visit and at time of delivery. The signature date from the time of delivery must match the date of service on the billing. The form must be completed, kept in the client’s file, and made available to the Health Care Authority (the agency) upon request.

This form is available for download on the agency’s Medicaid Forms web page and can be used immediately.