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 information highlights certain form completion instructions. Comprehensive ADA Dental Claim Form completion instructions

The 2024 ADA Dental Claim Form has been structurally revised to incorporate data content changes 8 that enable reporting: a) services delivered by a dentist in locum tenens (i.e., temporary substitute)

Comprehensive ADA Dental Claim Form completion instructions are printed in the CDT manual. Any updates to these instructions will be posted on the ADA’s web site (ADA.org).

Download the 2024 Dental Claim Form from CMS.

The laws of several states require the following statements to appear on the claim form: Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly

Check out the ADA Online Store for Dental Claim Form (2024 Version) Downloadable PDF.

The form supports reporting up to four diagnosis codes per dental procedure. This information is required when the diagnosis may affect claim adjudication when specific dental procedures may minimize the risks associated with the connection between …

The ADA Dental Claim Form was last structurally revised in 2012 to incorporate key data content changes that enables diagnosis code reporting that was also incorporated into the now current version of the HIPAA standard (837D v5010) electronic dental claim.

The treating, or rendering, dentist's signature and date the claim form was signed. Dentists should be aware that they have ethical and legal obligations to refund fees for services that are paid in advance but not completed.