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Revised Orthodontic Information form (HCA 13-666), effective 3/1/2022
Washington Apple Health·WA · Dentistry·Provider Alert
Effective date
Mar 1, 2022
We identified it
Jun 20, 2026
Summary
Washington State Health Care Authority revised the Orthodontic Information form HCA 13-666 effective March 1, 2022. All orthodontic authorization requests must use the new form or they will be rejected.
Action Required
By March 1, 2022: Orthodontic providers must download the revised Orthodontic Information form HCA 13-666 from the HCA Forms and Publications webpage (available February 1, 2022). Use only the new form for all orthodontic authorization requests. Requests submitted with old forms will be rejected.