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
( ICD-9 = B; 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
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
)
(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
Remaining
43. Replacement of Prosthesis
No
Yes (Complete 44)
44. Date of Prior Placement (MM/DD/CCYY)
37.
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
INSURANCE COMPANY/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.)
6. Date of Birth (MM/DD/CCYY) 7. Gender
M F
8. Policyholder/Subscriber ID (SSN or ID#)
9. Plan/Group Number 10. Patient’s Relationship to Person named in #5
Self Spouse Dependent Other
POLICYHOLDER/SUBSCRIBER INFORMATION
(For Insurance Company Named in #3)
Address, City, State, Zip Code
13. Date of Birth (MM/DD/CCYY) 14. Gender
M F
15. Policyholder/Subscriber ID (SSN or ID#)
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
21. Date of Birth (MM/DD/CCYY) 22. Gender
M F
23. Patient ID/Account # (Assigned by Dentist)
©2012 American Dental Association
J430D (Same as ADA Dental Claim Form – J430, J431, J432, J433, J434)
foldfold
fold
fold
Dental Claim Form
Delta Dental of Arizona
DDAZ-0154-rev0417
Delta Dental of Arizona
PO Box 43026
Phoenix, AZ 85080-3026
