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Benefits SUM Sample Dental Claim Form (B) Image 0
Benefits SUM Sample Dental Claim Form (B) Image 0
Benefits SUM Sample Dental Claim Form (B) Image 0
Benefits SUM Sample Dental Claim Form (B) Image 1
Benefits SUM Sample Dental Claim Form (B) Image 1
Benefits SUM Sample Dental Claim Form (B) Image 2
Benefits SUM Sample Dental Claim Form (B) Image 2

Benefits SUM Sample Dental Claim Form (B)

CPS_PR039B-P1
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A sample of the ADA Dental Claim Form used for reporting dental services to a patient's dental benefit plan The latest version of the ADA’s paper form reflects information included in the HIPAA standard electronic dental claim transaction. Comprehensive ADA Dental Claim Form completion instructions are printed in the CDT manual.