• Need Insurance?
  • Already a Member
  • For Employers
  • For Brokers
  • For Providers
  • Community
Skip Navigation
CareFirst Logo
Log in
  • Home
  • Join Our Networks
    • Professional
      • Credentialing Overview
      • How to Apply
      • CAQH Universal Credentialing
      • Credentialing FAQs
      • Find a Provider Rep
    • Institutional/Ancillary
      • Credentialing Overview
      • How to Apply
      • Credentialing Forms
      • Credentialing FAQs
      • Find a Provider Rep
    • Dental
      • Credentialing Overview
      • How to Apply
      • CAQH Universal Credentialing
      • Credentialing Forms
      • Credentialing FAQs
      • Find a Provider Rep
  • Programs/Services
    • Medical
      • Electronic Capabilities
      • Medical Policy
      • Pre-Cert/Pre-Auth (In-Network)
      • Pre-Cert/Pre-Auth (Out-of-Area)
      • Medical Forms
      • Medical News
    • Dental
      • Dental Overview
      • Dental Electronic Capabilities
      • Dental NPI & Payer Codes
      • Dental Clinical Criteria
      • Dental Forms
      • Dental News
      • Dental Seminar
      • Dental Wellness
    • Pharmacy
      • Pharmacy Exception Requests
      • Pharmacy Resources
      • Pharmacy Prior Authorization
    • Care Management
      • PCMH
      • PCMH News
      • Quality & Affordability
      • Clinical Resources
      • Profile Score
    • Wellness/Incentives
      • Blue Rewards
  • Resources
    • Administrative
      • CareFirst Direct
      • Update Practice Info
      • Manuals & Guides
      • Forms
      • Inquiries & Appeals
      • Medicare Appeals and Grievances
    • Claims
      • Claims Submission
      • Dental Claims Submission
      • NPI
      • Dental NPI & Payer Codes
      • Ancillary Claims
      • Corrected Claims
      • Medicare Secondary
      • Paper Claims
    • Resources
      • Find a Provider Rep
      • User Guides
      • Federal Employee Program
    • News/Training
      • Center for Provider Education
      • Newsletters
      • News Archives
  • Manuals and Guides
  • Print
    A
    A
    A

Dental

  • Dental Overview
  • Dental Electronic Capabilities
    • Dental FAQs
  • Dental NPI & Payer Codes
  • Dental Clinical Criteria
  • Dental Forms
  • Dental News
  • Dental Seminar
  • Dental Wellness
PDF icon

Viewing and printing this document requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

Dental Forms

Dental

Continuation of Care Form for Orthodontic Treatment
Dental Change in Provider Information Form
Dental Continuing Education Registration Form
Handicapping Labio-Lingual Deviations (HLD) Orthodontic Treatment Score Sheet
NPI Submission Form for Dental Providers
Salzmann Evaluation Form for Orthodontic Services
Uniform Dental Consultation Referral Form
CareFirst BlueCross BlueShield Advantage Dental Benefits Summary Core (HMO)
CareFirst BlueCross BlueShield Advantage Dental Benefits Summary Enhanced (HMO)
CareFirst BlueCross BlueShield Advantage Dental Benefits Summary Enhanced Add-On (HMO)
  • About Us
    • Transformation
    • We Stand Against Injustice
    • Company Overview
    • Our History
    • Corporate Offices & Locations
    • Service Area
    • Annual Reports
    • Media Releases
  • Legal & Mandates
    • Patient Rights & Responsibilities
    • Member's Privacy Policy
    • HIPAA
    • Health Care Fraud Prevention
    • Quality Improvement
    • Mental Health Parity
    • Machine Readable Data
  • Other Information
    • Community
    • Health Insurance Glossary
    • Contact Us
    • Send Us Your Feedback
Facebook Twitter YouTube LinkedIn Instagram

Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield Medicare Advantage is the shared business name of CareFirst Advantage, Inc. and CareFirst Advantage DSNP, Inc. CareFirst BlueCross BlueShield Community Health Plan Maryland is the business name of CareFirst Community Partners, Inc. CareFirst BlueCross BlueShield Community Health Plan District of Columbia is the business name of Trusted Health Plan (District of Columbia), Inc. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc.

In Virginia, CareFirst MedPlus and CareFirst Diversified Benefits are is the business names of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only.