Dental Claim Form
©American Dental Association, 1999 version 2000
©American Dental Association, 1999
1. Dentist’s pre-treatment estimate
Dentist’s statement of actual services
Specialty (see backside) 3. Carrier Name
4. Carrier Address2. Medicaid Claim
EPSDT
Prior Authorization #
5. City 6. State 7. Zip
8. Patient Name (Last, First, Middle) 9. Address 10. City 11. State
12. Date of Birth (MM/DD/YYYY)
/ /
13. Certificate #
14. Sex
M F
15. Phone Number
( )
16. Zip Code
PATIENT
17. Relationship to Certificateholder/Employee:
Self Spouse Child Other_____________________________________
18. Employer
Name____________________________ Address________________________
19. Cert.Hldr./Emp. ID#/SSN# 20. Employer Name 21. Group #
31. Is Patient covered by another plan
No (Skip 32–37) Yes: Dental or Medical
32. Certificate #
22. Certificateholder/Employee Name (Last, First, Middle) 33. Other Certificateholder’s Name
23. Address 24. Phone Number
( )
34. Date of Birth (MM/DD/YYYY)
/ /
35. Sex
M F
36. Plan/Program Name
25. City 26. State 27. Zip Code
OTHER POLICIES
37. Employer/School
Name________________________________ Address_____________________
28. Date of Birth (MM/DD/YYYY)
/ /
29. Marital Status
Married Single Other
30. Sex
M F
38. Certificateholder/Employee Status
Employed Part-time Status Full-time Student Part-time Student
40. Employer/School
Name_______________________________ Address______________________PO
CERTIFICATEHOLDER / EMPLOYEE
39. I have been informed of the treatment and associated fees. I agree to be responsible for all
charges for dental services and materials not paid by my dental benefit plan, unless 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 under applicable law, I authorize release of any information relating
to this claim.
X____________________________________________________________________
Signed (Patient/Guardian) Date (MM/DD/YYYY)
41. I hereby authorize payment of the dental benefits otherwise payable to me directly to the
below named dental entity.
X_______________________________________________________________
Signed (Employee/certificateholder) Date (MM/DD/YYYY)
42. Name of Billing Dentist or Dental Entity 43. Phone Number
( )
44. Provider ID # 45. Dentist Soc. Sec. or T.I.N.
46. Address 47. Dentist License # 48. First visit date of current
series:
49. Place of treatment
Office Hosp. ECF Other
50. City 51. State 52. Zip Code 53. Radiographs or models enclosed?
Yes, How many?_______ No
54. Is treatment for orthodontics?
Yes No
If service already commenced:
55. If prosthesis (crown, bridge, dentures), is this
initial placement?
Yes No
If no, reason for replacement:
____________________________
Date of prior placement:
____________________________
Date appliances placed
________________
Total mos. of treatment
remaining __________
BILLING DENTIST
56. Is treatment result of occupational illness or injury? No Yes
Brief description and dates___________________________________
57. Is treatment result of: auto accident? other accident? neither
Brief description and dates__________________________________________________
58. Diagnosis Code Index (optional)
1. ________________ 2. ________________ 3. ________________ 4. ________________ 5. ________________ 6. ________________ 7. ________________ 8. ________________
59. Examination and treatment plans – List teeth in order
Date (MM/DD/YYYY) Tooth Surface Diagnosis Index # Procedure Code Qty Description Fee
Admin. Use Only
60. Identify all missing teeth with “X”
Permanent
Primary
Total Fee
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 A B C D E F G H I J Payment by other plan
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T S R Q P O N M L K Max. Allowable
Deductible
61. Remarks for unusual services
Carrier %
Carrier pays
Patient pays
63. Address where treatment was performed62. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or
have been completed and that the fees submitted are the actual fees I have charged and intend to collect for those
procedures.
X _________________________________________________________________________________
Signed (Treating Dentist) License # Date
(MM/DD/YYYY)
64. City 65.State 66. Zip Code
CONTINENTAL AMERICAN INSURANCE COMPANY
P.O. BOX 84075 • COLUMBUS, GA • 31993
Toll-Free: 1-866-849-0017 Fax: 1-866-849-2970
Continental American Insurance Company
