Hld Score Sheet - Position the patient’s teeth in centric occlusion. Enter score “0” if condition is absent. Web procedure (use this score sheet and a boley gauge or disposable ruler): Record all measurements in the order given and round off to the nearest millimeter (mm). Complete this score sheet and submit along with a completed prior authorization request. (you will need this score sheet and a boley gauge or a disposable ruler) provider. Occlude patient or models in centric position. Web score one (1) for a crowded maxil ary arch and/or one (1) for a crowded mandibular arch, enter total on the score sheet and multiply by five (5). All necessary dental work completed? Yes ___ no ___ patient oral hygiene:
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You will need this form and a scaled millimeter ruler or a boley gauge. Web procedure (use this score sheet and a boley gauge or disposable ruler): If ectopic eruption (condition #10) exists in the anterior region of the same arch, count the condition that scores the most points. Enter score “0” if condition is absent. Position the patient’s teeth.
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Record all measurements in the order given and round off to the nearest millimeter (mm); Occlude patient or models in centric position. Web hld index scoring instructions. Absence of any conditions must be recorded by entering. Complete this score sheet and submit along with a completed prior authorization request.
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Absence of any conditions must be recorded by entering. Web procedure (use this score sheet and a boley gauge or disposable ruler): Position the patient's teeth in centric occlusion; A boley gauge or disposable ruler is required to calculate measurements when completing this form. Web score one (1) for a crowded maxil ary arch and/or one (1) for a crowded.
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Definitions are on the reverse side of form. Web score one (1) for a crowded maxil ary arch and/or one (1) for a crowded mandibular arch, enter total on the score sheet and multiply by five (5). Record all measurements in the order given and round off to the nearest millimeter (mm); Indicate by checkmark next to a, b and/or.
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With a boley gauge (or a disposable ruler) scaled in millimeters. Record all measurements in the order given and round off to the nearest millimeter (mm); Enter score “0” if condition is absent. Definitions are on the reverse side of form. Indicate by checkmark next to a, b and/or c which criteria you are submitting for review.
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With a boley gauge (or a disposable ruler) scaled in millimeters. Position the patient’s teeth in centric occlusion. If ectopic eruption (condition #10) exists in the anterior region of the same arch, count the condition that scores the most points. Absence of any conditions must be recorded by entering. Yes ___ no ___ patient oral hygiene:
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Indicate by checkmark next to a, b and/or c which criteria you are submitting for review. Record all measurements in the order given and round off to the nearest millimeter (mm). Occlude patient or models in centric position. Enter score “0” if condition is absent. Absence of any conditions must be recorded by entering.
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Record all measurements in the order given and round off to the nearest millimeter (mm). Absence of any conditions must be recorded by entering. Indicate by checkmark next to a, b and/or c which criteria you are submitting for review. Web hld index scoring instructions. (you will need this score sheet and a boley gauge or a disposable ruler) provider.
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Definitions are on the reverse side of form. Enter score “0” if condition is absent. Absence of any conditions must be recorded by entering. All necessary dental work completed? (you will need this score sheet and a boley gauge or a disposable ruler) provider.
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Record all measurements in the order given and round off to the nearest millimeter (mm); Occlude patient or models in centric position. (you will need this score sheet and a boley gauge or a disposable ruler) provider. Web procedure (use this score sheet and a boley gauge or disposable ruler): A boley gauge or disposable ruler is required to calculate.
Web procedure (use this score sheet and a boley gauge or disposable ruler): Record all measurements in the order given and round off to the nearest millimeter (mm). With a boley gauge (or a disposable ruler) scaled in millimeters. Record all measurements in the order given and round off to the nearest millimeter (mm); (you will need this score sheet and a boley gauge or a disposable ruler) provider. Web score one (1) for a crowded maxil ary arch and/or one (1) for a crowded mandibular arch, enter total on the score sheet and multiply by five (5). Web hld index scoring instructions. Position the patient’s teeth in centric occlusion. Occlude patient or models in centric position. Indicate by checkmark next to a, b and/or c which criteria you are submitting for review. Complete this score sheet and submit along with a completed prior authorization request. Absence of any conditions must be recorded by entering. Yes ___ no ___ patient oral hygiene: Position the patient's teeth in centric occlusion; You will need this form and a scaled millimeter ruler or a boley gauge. All necessary dental work completed? Enter score “0” if condition is absent. If ectopic eruption (condition #10) exists in the anterior region of the same arch, count the condition that scores the most points. A boley gauge or disposable ruler is required to calculate measurements when completing this form. Definitions are on the reverse side of form.