American Dental Association Dental Claim Form
ADVERTISEMENT
1Dental Claim Form
HEADER INFORMATION
1. Type of Transaction (Mark all applicable boxes)
Statement of Actual Services
Request for Predetermination/Preauthorization
EPSDT / Title XIX
POLICYHOLDER/SUBSCRIBER INFORMATION
2. Predetermination/Preauthorization Number
(For Insurance Company Named in #3)
Address, City, State, Zip Code
INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION
3. Company/Plan Name, Address, City, State, Zip Code
13. Date of Birth (MM/DD/CCYY)
14. Gender
15. Policyholder/Subscriber ID (SSN or ID#)
M
F
OTHER COVERAGE
16. Plan/Group Number
17. Employer Name
(Mark applicable box and complete items 5 -11. If none, leave blank.)
4. Dental?
Medical?
(If both, complete 5-11 for dental only.)
PATIENT INFORMATION
19. Reserved For Future
18. Relationship to Policyholder/Subscriber in #12 Above
Use
6. Date of Birth (MM/DD/CCYY)
7. Gender
Self
Spouse
Dependent Child
Other
8. Policyholder/Subscriber ID (SSN or ID#)
M
F
, State, Zip Code
9. Plan/Group Number
10. Patient’s Relationship to Person named in #5
Self
Spouse
Dependent
Other
21. Date of Birth (MM/DD/CCYY)
22. Gender
23. Patient ID/Account # (Assigned by Dentist)
M
F
RECORD OF SERVICES PROVIDED
25. Area
26.
24. Procedure Date
27. Tooth Number(s)
28. Tooth
29. Procedure
29a. Diag.
29b.
of Oral
Tooth
30. Description
31. Fee
(MM/DD/CCYY)
or Letter(s)
Surface
Code
Pointer
Qty.
Cavity
System
1
2
3
4
5
6
7
8
9
10
33. Missing Teeth Information (Place an “X” on each missing tooth.)
31a. Other
34
( ICD-9 = B; ICD-10 = AB )
Fee(s)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
34a. Diagnosis Code(s)
A _________________
C _________________
32. Total Fee
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
(Primary diagnosis in “A”)
B _________________
D _________________
35. Remarks
AUTHORIZATIONS
ANCILLARY CLAIM/TREATMENT INFORMATION
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all
38. Place of Treatment
39. Enclosures (Y or N)
)
charges for dental services and materials not paid by my dental
(Use “Place of Service Codes for Professional Claims”)
law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all
or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure
40. Is Treatment for Orthodontics?
41. Date Appliance Placed (MM/DD/CCYY)
of my protected health information to carry out payment activities in connection with this claim.
No (Skip 41-42)
Yes (Complete 41-42)
X
_____________________________________________________________________________
Patient/Guardian Signature
Date
42. Months of Treatment
43. Replacement of Prosthesis
44. Date of Prior Placement (MM/DD/CCYY)
No
Yes (Complete 44)
37.
to the below named dentist or dental entity.
45. Treatment Resulting from
Occupational illness/injury
Auto accident
Other accident
X
_____________________________________________________________________________
Subscriber Signature
Date
46. Date of Accident (MM/DD/CCYY)
47. Auto Accident State
BILLING DENTIST OR DENTAL ENTITY
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
(Leave blank if dentist or dental entity is not
submitting claim on behalf of the patient or insured/subscriber.)
53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require
multiple visits) or have been completed.
48. Name, Address, City, State, Zip Code
X
________________________________________________________________________________
Signed (Treating Dentist)
Date
54. NPI
55. License Number
56a. Provider
56. Address, City, State, Zip Code
Specialty Code
49. NPI
50. License Number
51. SSN or TIN
52. Phone
52a. Additional
57. Phone
58. Additional
Number (
)
-
(
)
-
Provider ID
Number
Provider ID
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business