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
39
PRACTICE MANAGEMENT
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