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:

• Download the ADA Dental Claim Form completion instructions (PDF)

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 (dentalcode@ada.org) or via telephone (ADA Members, please use the toll-free number on the back of your membership card / Direct Dial 312-440-2500).

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

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