ADA Dental Claim Form

1.Type of Transaction (Mark all applicable boxes)

Statement of Actual Services EPSDT / Title XIX Request for Predetermination / Preauthorization

2. Predetermination / Preauthorization Number

INSURANCE COMPANY / DENTAL BENEFIT PLAN INFORMATION

3. Company Plan / Name

Address

City

State

Zip Code

OTHER COVERAGE

4. Other Dental or Medical Coverage?

No (Skip 5-11) Yes (Complete 5-11)

5. Name of Policyholder /Subscriber

Last Name

First Name

Middle

Initial

Suffix

6. Date of Birth

8. Policyholder/Subscriber ID (SSN or ID #)

9. Plan / Group Number

11. Other Insurance Company / Dental Benefit Plan Name

Address

City

State

Zip Code

POLICYHOLDER / SUBSCRIBER INFORMATION (For Insurance Company Named in #3)

12. Policyholder/Subscriber Last Name

First Name

Middle

Initial

Suffix

Address

City

State

Zip

13. Date of Birth

15. Policyholder/Subscriber ID (SSN or ID #)

16. Plan / Group Number

17. Employer Name

PATIENT INFORMATION

18. Relationship to Policyholder / Subscriber in #12 Above

Self

Spouse

Dependent Child

Other

20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code

21. Date of Birth

23. Patient ID / Account #

RECORD OF SERVICES PROVIDED

Add Record

24. Remarks

Authorizations

25. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan unless prohibited by 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 of my protected health information to carry out payment activities in connection with this claim.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient / Guardian Signature

Date

26. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity.

Subscriber Signature

Date

Ancillary Claim / Treatment Information

27. Place of Treatment

Provider's Office

Hospital

ECF

Other

28. Number of Enclosures (00 to 99)

Radiographs

Oral Image

Models

29. Is Treatment for Orthodontics?

No Yes

If yes, Date Appliance Placed

If yes, Months of Treatment Remaining

If yes, Date Prior Placement

33. Treatment Resulting From

Occupational Illness / INjury

Auto Accident

Other Accident

34. Date of Accident

35. Auto Accident State

BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber)

36. Name, Address, City, State, Zip Code

37. NPI

38. License Number

39. SSN or TIN

40. Phone Number

41. Additional Provider ID

TREATING DENTIST AND TREATMENT LOCATION INFORMATION

I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple v1s1ts) or have been completed.

Signed (Treating Dentist)

Date

42. NPI

43. License Number

44. Address , City, State, Zip Code

45. Provider Special

46. Phone Number

47. Additional Provider

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