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Dental Claim Form

RECORD OF SERVICES PROVIDED24. Procedure Date(MM/DD/CCYY)25. Areaof Oral Cavity26. Tooth System27. Tooth Number(s)or Letter(s)28. Tooth Surface29. ProcedureCode29a. 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 Fee35. RemarksAUTHORIZATIONSANCILLARY Claim /TREATMENT INFORMATION36. I have been informed of the treatment plan and associated fees.

Occupational illness/injury Auto accident Other accident 46. Date of Accident (MM/DD/CCYY) 47. Auto Accident State BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber.) TREATING DENTIST AND TREATMENT LOCATION INFORMATION 53.

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