RECORD OF SERVICES PROVIDED 24. Procedure Date (MM/DD/CCYY) 25. Area of Oral Cavity 26. Tooth System 27. Tooth Number(s) or Letter(s) 28. Tooth Surface 29. Procedure Code 29a. Diag. Pointer 29b. Qty. 30. Description 31. Fee 1 2 3 4 5 6 7 8 9 10 33. Missing Teeth Information (Place an “X” on each missing tooth.) 34. Diagnosis Code List Qualifier ( ICD-10 = AB ) 31a. Other Fee(s) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 34a. Diagnosis Code(s) A _________________ C _________________ 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 (Primary diagnosis in “A”) B _________________ D _________________ 32. Total Fee 35. Remarks AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION 36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim. X _____________________________________________________________________________ Patient/Guardian Signature Date 38. Place of Treatment n (e.g. 11=office 22=O/P Hospital) (Use “Place of Service Codes for Professional Claims”) 39. Enclosures (Y or N) 40. Is Treatment for Orthodontics? No (Skip 41-42) Yes (Complete 41-42) 41. Date Appliance Placed (MM/DD/CCYY) 42. Months of Treatment 43. Replacement of Prosthesis No Yes (Complete 44) 44. Date of Prior Placement (MM/DD/CCYY) 37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity. X _____________________________________________________________________________ Subscriber Signature Date 45. Treatment Resulting from Occupational illness/injury Auto accident Other accident 46. Date of Accident (MM/DD/CCYY) 47. Auto Accident State BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber.) TREATING DENTIST AND TREATMENT LOCATION INFORMATION 53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed. X________________________________________________________________________________ Signed (Treating Dentist) Date 48. Name, Address, City, State, Zip Code 54. NPI 55. License Number 56. Address, City, State, Zip Code 56a. Provider Specialty Code 49. NPI 50. License Number 51. SSN or TIN 52. Phone Number ( ) - 52a. Additional Provider ID 57. Phone Number ( ) - 58. Additional Provider ID HEADER INFORMATION 1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services Request for Predetermination/Preauthorization EPSDT / Title XIX 2. Predetermination/Preauthorization Number DENTAL BENEFIT PLAN INFORMATION 3. Company/Plan Name, Address, City, State, Zip Code OTHER COVERAGE (Mark applicable box and complete items 5-11. If none, leave blank.) 4. Dental? Medical? (If both, complete 5-11 for dental only.) 5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix) 6. Date of Birth (MM/DD/CCYY) 7. Gender M F U 8.Policyholder/Subscriber ID (Assigned by Plan) 9. Plan/Group Number 10. Patient’s Relationship to Person named in #5 Self Spouse Dependent Other 11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code POLICYHOLDER/SUBSCRIBER INFORMATION (Assigned by Plan Named in #3) 12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code 13. Date of Birth (MM/DD/CCYY) 14. Gender M F U 15.Policyholder/Subscriber ID (Assigned by Plan) 16. Plan/Group Number 17. Employer Name PATIENT INFORMATION 18. Relationship to Policyholder/Subscriber in #12 Above Self Spouse Dependent Child Other 19. Reserved For Future Use 20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code 21. Date of Birth (MM/DD/CCYY) 22. Gender M F U 23. Patient ID/Account # (Assigned by Dentist) ©2019 American Dental Association J430 (Same as ADA Dental Claim Form – J431, J432, J433, J434, J430D) Dental Claim Form To reorder call 800.947.4746 or go online at ADAcatalog.org fold fold fold fold