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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 information:

There are three sets of completion instructions available for download. First is the comprehensive instruction for all items (#’s 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.

Third is additional guidance on reporting Area of the Oral Cavity, Tooth Numbers or Tooth Surfaces, which concern item #s 25, 27 and 28. 

Technical questions concerning the ADA Dental Claim Form's content or completion should be directed to the ADA's Practice Institute staff via email ( 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.