ADA Dental Claim Form
POLICYHOLDER/SUBSCRIBER INFORMATION
Policyholder/Subscriber Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Name
*
Dental Insurance Company Name
*
Dental Insurance Claim Address (may appear on back of card)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policyholder/Subscriber ID (SSN or ID#)
*
ID Card
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Patient Information
Patient Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Policyholder/Subscriber
*
Self
Spouse
Dependent Child
Other
Student Status
Full Time
Part Time
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
AUTHORIZATIONS
I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by 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.
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the Amy Richter Orthodontics.
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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