Transcription of Dental Claim Form
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Example: bachelor of science
Dental Claim Form
RECORD OF SERVICES PROVIDED24. Procedure Date(MM/DD/CCYY)25. Area of Oral Cavity26. Tooth System27. Tooth Number(s)or Letter(s)28. Tooth Surface29. Procedure Code29a. Diag. Pointer29b. Description31. Fee1234567891033. Missing Teeth Information (Place an X on each missing tooth.)34. Diagnosis Code List Qualifier ( ICD-10 = AB ) 31a. Other Fee(s) 123456789 1011121314151634a. Diagnosis Code(s)A _____C _____32313029282726252423222120191817(Pr imary diagnosis in A )B _____D _____ 32. Total Fee 35. RemarksAUTHORIZATIONSANCILLARY Claim /TREATMENT INFORMATION36.
DIAGNOSIS CODING 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 patient’s oral and systemic health conditions.
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