HealthCheck D0999 Periodic oral evaluation (additional) Submit medical Other Services documentation to D2999 Single unit crown. Tooth number support special requests. D4999 Surgical procedure HealthCheck referral D5999 Nonsurgical procedure required. D7999 D9999 SECTION III AUTHORIZED SIGNATURE – SIGNATURE Requesting Provider Date Signed – SECTION IV ADDITIONAL INFORMATION – Indicate any additional information (e.g., diagnostic and clinical information) in the space provided.
HealthCheck Other Services D0999 D2999 D4999 D5999 D7999 D9999 Periodic oral evaluation (additional) Single unit crown. Tooth number Surgical procedure Nonsurgical procedure Submit medical documentation to support special requests. HealthCheck referral required. SECTION III – AUTHORIZED SIGNATURE SIGNATURE – Requesting Provider Date Signed SECTION IV – ADDITIONAL INFORMATION Indicate any additional information (e.g., diagnostic and clinical information) in the space provided.
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