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Download the current version of the 2024 ADA Dental Claim Form © (PDF) Download the Comprehensive ADA Dental Claim Form Completion Instructions (PDF) for all items (#’s 1 through 58)
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- ADA Dental Claim Form
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- Dental Insurance Frequently Asked Questions
Comprehensive ADA Dental Claim Form completion instructions are printed in the CDT manual. Any updates to these instructions will be posted on the ADA’s web site (ADA.org).
The following information highlights certain form completion instructions. Comprehensive ADA Dental Claim Form completion instructions
Comprehensive ADA Dental Claim Form completion instructions are posted on the ADA’s web site (https://www.ADA.org/en/publications/cdt/ada-dental-claim-form). GENERAL INSTRUCTIONS
The ADA Dental Claim Form was last structurally revised in 2012 to incorporate key data content changes that enables diagnosis code reporting that was also incorporated into the now current version of the HIPAA standard (837D v5010) electronic dental claim.
The ADA Dental Claim Form was revised in 2019 with editorial changes to form captions and check box options for gender (M, F and U) to be consistent with the HIPAA standard electronic dental claim (837D).
The ADA Dental Claim Form has been revised to incorporate key changes to the HIPAA standard electronic dental claim transaction. This version of the form, front and reverse sides, is illustrated on the next two pages. Comprehensive completion instructions for this version (2012 © American Dental Association) follow the illustration.