The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental benefit plan) is visible in a standard #9 window envelope (window to the left). Any updates to these instructions will be posted on the ADA’s web site (ADA.org).Ī. Comprehensive ADA Dental Claim Form completion instructions are printed in the CDT manual. The following information highlights certain form completion instructions. I hereby certify that the procedures as indicated by date are in progress (for procedures that require Submitting claim on behalf of the patient or insured/subscriber.)ĥ3. TREATING DENTIST AND TREATMENT LOCATION INFORMATION To the below named dentist or dental entity.īilling Dentist or Dental Entity (Leave blank if dentist or dental entity is not I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly Of my protected health information to carry out payment activities in connection with this claim. To the extent permitted by law, I consent to your use and disclosure Law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all (Use “Place of Service Codes for Professional Claims”) I agree to be responsible for allĬharges for dental services and materials not paid by my dental benefit plan, unless prohibited by I have been informed of the treatment plan and associated fees. Patient ID/Account # (Assigned by Dentist)ģ6. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip CodeĢ3. Patient’s Relationship to Person named in #5ġ1. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Codeġ0. Policyholder/Subscriber ID (SSN or ID#)Ģ0. Relationship to Policyholder/Subscriber in #12 AboveĨ. Name of Policyholder/Subscriber in # 4 (Last, First, Middle Initial, Suffix)ġ8. (If both, complete 5-11 for dental only.)ĥ. Other coverage (Mark applicable box and complete items 5-11. Company/Plan Name, Address, City, State, Zip Codeġ5. ![]() Insurance Company/Dental Benefit Plan Informationģ. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code Predetermination/Preauthorization Numberġ2. POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in #3)Ģ. Request for Predetermination/Preauthorization Type of Transaction (Mark all applicable boxes) Landlord (Tenant) Recommendation Letterġ.
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