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.
The current version is 2012©American Dental Association, and a sample is available for your informaiton:
- 2012 ADA Dental Claim Form (PDF/1.4MB)
There are two sets of completion instructions available for download. First is the comprehensive instruction for all items (#1 through 58) on form. These will be used most frequently when reporting dental procedure:
The second instructions are applicable only when reporting procedure code D9985, and concern items # 24 through 32.
Technical questions concerning the ADA Dental Claim Form's content or completion should be directed to the ADA's Practice Institute staff via e-mail (firstname.lastname@example.org) or via telephone (ADA Members, please use the toll-free number on the back of your membership card / Direct Dial 312-440-2500).