24. Procedure Dille (MMIDDICCYY)

~Cavity

26. Toolt1 Syl1ern

Zl. Tooth Number(s) or Letter(a)

28.1both Surlaoe

29. Procadura Code 30. Deaa1ptlon 31.Fee

Dille

1

2

3

5

8

7

10

HEADER INFORMATION

1. Type ol Transaction (Mark all applicable boxaa)

0 Slalament ol Actual Services 0 Request lor Predetennlnatlon/Preauthorlzallon

0 EPSDT/Tltle XIX

2. Predetennlnllllon/Preaulhortzatlon Number POLICYHOLDERJSUBSCRIBER INFORMAllON (For Insurance Company Named in #3)

12. Policyholder/Subsc:riber Name (Las~ First, Middle lnijial, Suffix), Addrws, City, State, Zip Code

INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMAllON

3. Company/Plan Name, Addreas, City, State, Zip Code

13. Date ol Birth (MMIDDICCYY) 114. Gender 115. Policyholder/Subscriber ID (SSN or lOll)

OM OF

OTHER COVERAGE 16. Plan/Group Number 117. Employer Nama

4. Other Dental or Medical Coverage? 0 No (Skip 5-11) Ovae (Complete5-11)

5. Nama ol Pollcyholdei1Subecrtber In (Last, First, Mkldla Initial, Su111x) « PATIENT INFORMATION

-ll 1 B. Relationship 1o Policyholder/Subscriber in 1112 Above 119. S1udent Sllllus

6. Oat& ol Birth (MMIDDICCYY) 7. Gander I B. Pollcyholder/Subecrtber ID (SSN or lOll) 0 SeH 0 Spouse 0 Dependent Child 0 Other OFTS OPTS

OM OF 20. Nama (Last, First, Middle lnhlal, Sulnx), Addreas, City, State, Zip Code

i-

9. Plan/Group Number 10. Patient's Relationship lo Person Named in 115

0 san 0 Spouse 0 Dependant 0 Olhar

11. Other Insurance Company/Dental Benefit Plan Name, Address, City, Slate, Zip Coda

21. Date ol Birth (MMIDDICCYY) 122. Gander 123. Patient ID/Aocount 11 (Assigned by Dentist)

OM OF

RECORD OF SERVICES PROVIDED

~

I I

I I

' ' 4 I

I

I I

' ' I

I

8 I I

9 ' ' I I

MISSING TEETH INFORMA110N Permanent Prirnory 32.0ther Fee( a)

I I

a 1 9 I F G H I J ' 1 2 3 4 5 6 7 10 11 12 13 14 15 16 A B D E c ' 34. (PIIIce an 'X" on each missing looltl) '

32 31 30 29 2B 27 26 25124 23 22 21 20 19 18 17 T R s a P I o N M L K 33.Total Feel I I

-ll 35. Remarks i-

AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMA110N

36. I have been Informed ol1he treatment plan and associated lees. I agraelo be reaponalble lor all charges lor dental services and materials not paid by my dental benefij plan, unless prohibited by law, or the lnlating dentist or dental practice has a oontractual agreement wHh my plan prohibiong all or a portion olsuch chargee. To the extllnt permitted by law, I ooneent lo your uaa and discloeura ol my protected health lnlonnaUon 1o carry out payment actlvhles In oonnectlon whh lhls claim.

3B. Placa ol Treatment 139. Number ol Encloaurea 1o 99) RodiDIJol>h(ol Onollmog a) -l(o)

JOO 0 Provide~• omce 0 Hoapltal 0 ECF 0 Other D D D

40. Is Tnsatment for Orthodontics? 41. Date Appliance Placed (MMIDDICCYY)

X 0 No (Skip 41-42) Oves (Complete 41-42)

Pa11ent/Guanllan signature Date 42. Monlh~ .ol Treatment Rema1mng

143. Replacement o1 Prosthesis? 44. Date ol Prior Placement (MMIDDICCYY)

37. I heraby aUihorlze and dlrec1 payment ol the dental ban11111B otherwise payable 1o me, dlrec11y 1o the below named denUstor dental anllly.

0 No 0 Yea (Complete 44)

45. Treabnent Resulting from

X 0 Occupational illnaas/injury 0 Aulo accident 0 Olher accident

Subecrlber signature 46. Oat& ol Accident (MMIDDICCYY) I 47. Auto Accident Stille

BILLING DEN11ST OR DENTAL ENTITY (Leave blank If dentlat or dental entity Is not submnung claim on behalf ol the patient or lnsuredlaubscrtber)

TREAT1NG DENTIST AND TREATMENT LOCA110N INFORMATION

53. I heAiby certify that lhe procedures as indicated by date are in progrBSS (for procedures thai require muhiple vlalls) or have bean completed.

48. Name, Addraes, City, S1ete, Zip Coda

X Signed (Trealing Dentist) Date

54.NPI I 55. Licansa Number

56. Addreas, City, State, Zip Coda l~&de 49. NPI 150. Ucanae Number 151. SSN or TIN

52. Phone Number ( ) - 1 52A- Addlllonal

Provider ID 57. Phone

Number ( ) - 156. AddHional Provider ID

02006 American Dental Association To reorder oaii1-80<HI47-4748 or go online a1 www.adacatalog.org J400 (Same as ADA Dental Claim Fonn-J401, J402, J403, J404)

American Dental Association Dental Claim Form

Comprehensive completion instructions for the ADA Dental Claim Form are found in the current version of the CDT manual published by the ADA. Five relevant extracts from that manual follow.