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Using the ADA Dental Claim Form in Your Practice

The current version of the ADA Dental Claim Form is used for pre-determination and for reporting dental services to a patient’s dental benefit plan. ADA policy promotes use and acceptance of the form by dentists and payers. The latest version of the ADA’s paper form reflects information included in the HIPAA standard electronic dental claim transaction.

A sample of the ADA Dental Claim Form, and its completion instructions, are available for download with links below.

Technical questions concerning the form's content or completion should be directed to the ADA's Practice Institute staff via email (dentalcode@ada.org) or via telephone (800-621-8099).

  • For information about licensing of the ADA Dental Claim Form, please visit the ADA Catalog.
  • For any questions regarding pricing or purchasing copies of the ADA Dental Claim Form, please visit the ADA Catalog or call 800-947-4746.

The ADA Dental Claim Form and the CDT manual are copyrighted documents. Reproduction of copyrighted information is subject to a licensing agreement.

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