ADA Claim Form

Dentist **AMERICAN DENTAL ASSOCIATION DENTAL CLAIM FORM** **1. Type of Transaction (Mark all applicable boxes)** [ ] Predetermination [ ] Initial [X] Replacement [ ] Reevaluation **2. Type of Service (Mark all applicable boxes)** [X] Dental [ ] Medical [ ] Orthodontic [ ] Hospital [ ] Accident [ ] Occupational Disease [ ] Other **3. Reason for Visit (Briefly describe)** Patient presenting with discomfort in the lower left quadrant. Follow-up for previously placed crown on tooth #19. **4. Patient Information** a. Patient Name: Jane Smith b. Date of Birth: 15/03/1985 c. Sex: Female d. Address: 123 Oak Avenue, Anytown, AB1 2CD e. Phone: 07700 900123 **5. Subscriber Information (if different from patient)** a. Subscriber Name: John Smith b. Subscriber Date of Birth: 20/07/1980 c. Subscriber Sex: Male d. Subscriber Address: 123 Oak Avenue, Anytown, AB1 2CD e. Subscriber Phone: 07700 900456 f. Relationship to Patient: Spouse **6. Insurance Company Information** a. Company Name: DentalCare Insurance Ltd. b. Address: 456 Elm Street, Cityville, CV1 3DE c. Policy Number: DCI-0123456789 d. Group Number: GRP-9876 **7. Referring Dentist (if applicable)** a. Name: Dr. Emily White b. Address: 789 Pine Lane, Townsville, TS2 4FG **8. Services Rendered** a. Date of Service: 01/11/2024 b. Tooth Number(s): 19 c. Area of Oral Cavity (e.g., quadrant, arch): Lower Left Quadrant d. Procedure Code: D2750 e. Description of Service: Crown - porcelain fused to high noble metal f. Fee for Service: £1200.00 g. Diagnosis Code: K02.9 (Dental caries, unspecified) **9. Radiographs or Models Enclosed?** [X] Yes [ ] No a. Number: 2 b. Type: Periapical **10. Total Fee: £1200.00** **11. Amount Paid by Patient: £200.00** **12. Amount Due from Insurance: £1000.00** **13. Dentist's Signature:** Dr. Sarah Jenkins (Digital Signature) **14. Date Signed:** 01/11/2024