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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. I agree to be responsible for all charges for Dental services and materials not paid by my Dental benefit plan, unless prohibited by law, or the treating dentist or Dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges.

J430 (Same as ADA Dental Claim Form – J431, J432, J433, J434, J430D) To reorder call 800.947.4746 or go online at adacatalog.org fold fold fold fold Dental Claim Form U 7. Gender U 22. Gender M F 14. Gender M F M F U

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Electronic Funds Transfer (EFT) / Direct Deposit Agent’s ...

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Electronic Funds Transfer (EFT) / Direct Deposit Agent’s Authorization Agreement / Delta Dental of New Mexico SECTION A Instructions Please complete Sections B, C and D and return this Electronic Funds Transfer (EFT)/Direct Deposit Authorization

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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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