ADA Dental Claim Form
The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. ADA policy promotes use and acceptance of the most current version of the ADA Dental Claim Form by dentists and payers.
Revised Effective July 1, 2012
The ADA Dental Claim Form has been revised to reflect changes to the HIPAA standard electronic dental claim transaction that are effective this year. This version, front and reverse sides, is available for your review:
- 2012 ADA Dental Claim Form (PDF/1.4MB)
Comprehensive form completion instructions for this version (© 2012 American Dental Association) are also available:
Technical questions concerning the ADA Dental Claim Form's content or completion should be directed to the ADA's Council on Dental Benefit staff via e-mail (email@example.com) or via telephone (ADA Members, please use the toll-free number on the back of your membership card / Direct Dial 312-440-2500).