Dental Claim Form (2012 Version)
The ADA Dental Claim Form was revised in 2012 to incorporate
a significant change in the HIPAA standard, which now enables
a dentist to include a diagnosis code when needed on a claim.
The downloadable version of the ADA Dental Claim Form allows
immediate access and requires no shipping. This is the most recent
version of the form. Not for online use.
J430
|
8½” x 11”, 100/pad
|
Members $15.00
|
Retail $22.50
J430D
|
Downloadable PDF
|
Members $29.95
|
Retail $44.95
J431
|
8.5” x 11”, Two-part carbonless, 100/pack
|
Members $20.00
|
Retail $30.00
J432
|
8.5” x 11”, Bond Stock, 250/pack
|
Members $30.00
|
Retail $45.00
J434
|
Bond in Red Ink, 100/pad
|
Members $15.00
|
Retail $22.50
ADA Health History Form
Clear two-sided layout and simple wording make form completion
easy. Includes questions related to intravenous bisphosphonates
and alendronates, and reflects the most recent AHA premedication
guidelines. Also available as a download for posting on practice
websites. Just download the PDF form and print — no shipping
or handling charges! Or link to the document from your practice’s
website and give patients the option to fill it out before they visit.
S500
|
English, 8½” x 11”, 100/pad
|
Members $15.00
|
Retail $22.50
S501
|
Spanish, 8½” x 11”, 100/pad
|
Members $15.00
|
Retail $22.50
S500D
|
English, Downloadable PDF
|
Members $29.95
|
Retail $44.95
S501D
|
Spanish, Downloadable PDF
|
Members $29.95
|
Retail $44.95
Motivate and
educate patients
with colorful wall art!
Framed prints are produced on high quality
photographic paper on a durable matte
surface, so no glass is necessary. Hardware
included for easy mounting. View more
designs online at ADAcatalog.org.
THREE SIZES AVAILABLE
SMALL 16” x 20”
MEDIUM 22” x 28”
LARGE 24” x 36”
THREE FINISHES AVAILABLE
BRUSHED STEEL 1⅛”
MAHOGANY WOOD 1¼”
BLACK WOOD 1¼”
Order Your Artwork
SMALL FRAMED
QTY MEMBER RETAIL
EACH $135.00 $203.00
3+ $110.00 $165.00
SMALL UNFRAMED
QTY MEMBER RETAIL
EACH $70.00 $105.00
3+ $50.00 $75.00
MEDIUM FRAMED
QTY MEMBER RETAIL
EACH $170.00 $255.00
3+ $140.00 $210.00
MEDIUM UNFRAMED
QTY MEMBER RETAIL
EACH $125.00 $188.00
3+ $100.00 $150.00
LARGE FRAMED
QTY MEMBER RETAIL
EACH $200.00 $300.00
3+ $165.00 $248.00
LARGE UNFRAMED
QTY MEMBER RETAIL
EACH $160.00 $240.00
3+ $130.00 $195.00
BEST SELLER
| DAW014
DAW021
NEW
| DAW100
NEW
| DAW102
DAW020
NEW
| DAW101
DAW027
Left
DAW005
Right
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ORDER BY PHONE: 800.947.4746
FORMS | WALL ART
ORDER ONLINE: ADACATALOG.ORG
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PRACTICE MANAGEMENT