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 following materials are prepared by ADA Practice Institute staff with contributions from the ADA Council on Dental Benefit Programs and other internal and external knowledge experts.

ADA Dental Claim Form and Completion Instructions

The current version (2019©) sample is available for download here:

Download the comprehensive completion instruction for all items (#’s 1 through 58) on this form.

Completion Instructions Supplement 1 – Reporting Oral Cavity, Tooth Numbers or Tooth Surfaces

This guide concerns claim form item #s 25, 27, and 28.  It specifies, by CDT code, when Area of the Oral Cavity, Tooth Numbers or Tooth Surfaces should be reported.

Completion Instructions Supplement 2 – Guide to Reporting D9985

These instructions concern claim form items # 24 through 32 and are applicable only when reporting procedure code “D9985 sales tax.”

Technical questions concerning the ADA Dental Claim Form's content or completion should be directed to the ADA's Practice Institute staff via email (dentalcode@ada.org). You can also reach out to us from 8:00 a.m. to 5 p.m. Central time, Monday through Friday by phone 800.621.8099.

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, including one that may be individually completed or printed. please visit the ADA Catalog or call 800.947.4746.