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American Dental Association Claim Form

Dental Claim form HEADER INFORmATION 1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services Request for Predetermination/Preauthorization EPSDT / Title XIX 2. Predetermination/Preauthorization Number INSURANCE COmPANy/ Dental BENEFIT PlAN INFORmATION 3. Company/Plan Name, Address, City, State, Zip Code OTHER COVERAgE (Mark applicable box and complete items 5 -11. If none, leave blank.) 4.

To reorder call 800.947.4746 . J430D (Same as ADA Dental Claim Form – J430, J431, J432, J433, J434) or go online at . adacatalog.org ; The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental

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J430 (Same as ADA Dental Claim Form – J431, J432, J433, J434, J430D) Dental Claim Form To reorder call 800.947.4746 or go online at ADAcatalog.org fold fold fold fold. The following information highlights certain form completion instructions. Comprehensive ADA Dental Claim Form completion instructions

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J400 (Same as ADA Dental Claim Form - J401, J402, J403, J404) To Reorder call 1-800-947-4746 orgo online at www.adacatalog.org ...

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