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's current version (©2012) by dentists and payers. ADA paper form content reflects information included in the HIPAA standard electronic dental claim transaction.
A sample ADA Dental Claim Form, its comprehensive completion instructions, and more are available for download.
Technical questions concerning the form's content or completion should be directed to the ADA's Practice Institute staff via email (firstname.lastname@example.org) or via telephone (800-621-8099).
The ADA Dental Claim Form and the CDT manual are copyrighted documents. Reproduction of copyrighted information is subject to a licensing agreement.