 Overview
The ADA Dental Claim Form provides a common format for reporting dental services to a patient’s dental benefit plan. ADA policy promotes use and acceptance of the most current version of the ADA Dental Claim Form by dentists and payers.
Three samples of the current ADA Dental Claim Form are available for your review. Comprehensive form completion instructions are contained in the ADA publication titled CDT – Current Dental Terminology.
- Front and reverse sides of the claim form | PDF file/489k
- Front of the form showing print positions (X) | PDF file/341k
- Front of the form showing print positions (X) over a print layout grid (PICA—6 rows per vertical inch x 10 columns per horizontal inch) | PDF file/505k
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Additional
Resources
The ADA Dental Claim Form and the CDT manual are copyrighted documents. Reproduction of copyrighted information is subject to a licensing agreement.
- For information about licensing of the ADA Dental Claim Form, please see CDT.
- For any questions regarding pricing or purchasing copies of the ADA Dental Claim Form, please visit the ADA Catalog or call 800-947-4746.
- Technical questions concerning the ADA Dental Claim Form’s content or completion should be directed to the ADA’s Council on Dental Benefit staff via e-mail (dentalcode@ada.org) or via telephone (ADA Members, please use the toll-free number on the back of your membership card / Direct Dial 312-440-2500).
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