Dental Claim Form (2024 Version) Downloadable PDF

The ADA Dental Claim Form was revised for 2024 with editorial changes, additional fields to document treatment provided by a Locum Tenens dentist and the patient’s last SRP date, and to update provider specialty coding information. Revisions to the current version harmonize data content with the HIPAA standard electronic claim transaction (837D). This is the most recent version of the form.

ADA Dental Claim Form completion instructions and other pertinent information are published online at https://www.ada.org/publicatio.... These materials are PDF files that can be downloaded at no additional cost. The form has been updated to meet Adobe and PAC accessibility requirements for screen readers.