Transcription of American Dental Association Dental Claim Form
1 -~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)
2 ,Address,City,State,ZipCodeDentistNameXA ddress1 Signed(TreatingDentist) ~ ,City,Stale, \ () () ~-~- 2006 AmericanDentalASSOC iationJ400(SameasADAD entalClaimForm-J401, J402, J403,J404)
