ADA 2019 Claim Form for Licensees

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. This version of the ADA form incorporates editorial changes to further its consistency with the 837D.

Please download your copy of the ADA 2019 Claim Form and start using this version immediately.

Attachments

• Follow Link ADA 2019 Dental Claim Form_J430.pdf
• Follow Link ADA 2019 Claim Form Completion Instructions.pdf