A patient responsibility form is a tool for use when an MCNA member's treatment plan requires the provision of services that are not covered by Medicaid and MCNA. It should also be used for elective procedures that are not medically necessary. The form will help you ensure that such treatment is adequately documented in the member's dental record after discussion with the member, or his or her parent or responsible party. To meet the documentation requirements for non-covered services, the form should clearly include the prices of all services and the signature of the member, parent, or responsible party.