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American Dental Association Dental Claim Form

-~AmericanDentalAssociationDentalClaimFo rmHEADER (Markallapplicableboxes) (ForInsuranceCompanyNamedin#3) (Last,First,MiddleInitial,Suffix),Addres s,City,State,ZipCodeINSURANCE ,Address,City,State, (MM/DD/CCYY)11De~deDF115 Policyholder/SubscriberID(SSNorID#) (Skip5-11)oYes(Complete5-11) #4(Last,First,MiddleInitial,Suffix) # (MM/DD/CCYY) (SSNorID#) (Last,First,MiddleInitial,Suffix),Addres s,City,State, 'sRelationshiptoPersonNamedin# ,Address,City,State, (MMIDD/CCYY)122~:eDF 123. PatientID/Account# (AssignedbyDentist) (s) (MM/DD/CCYY)ofOralToothorLelter(s) :23:4:5:6:7:--8:910 (s)34.(Placean'X'oneachmissingtooth) (00to99)chargesfordentalservicesandmater ialsnotpaidbymydentalbenefitplan,unlessp rohibitedbylaw,oroProvider'sOffice0 Hospilal0 ECF0 OtherRaO(S)arDIS)0thetreatingdentistorde ntalpracticehasa contractualagreementwithmyplanprohibitin gallora ,I (MMIDD/CCYY) (Skip41-42)oYes(Complete41-42) (MM/DD/CCYY) herebyauthorizeanddirectpaymentof thedentalbenefitsotherwisepayabetome,dir ectlytoIhebelownamedoNo0 Yes(Complete44) (MM/DD/CCYY) (Leaveblankif dentistordentalentityis notsubmittingTREATINGDENTISTANDTREATMENT LOCATIONINFORMATION claimonbehalfofthepatientorinsured/subsc riber) herebycertifythattheproceduresasindicate dbydateareinprogress(forproceduresthatre qUiremultiplevisits) ,Address,City,State,ZipCodeDent

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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