DenTAl ClAIm form (2012 verSIon)
The ADA Dental Claim Form was revised in 2012 to
incorporate a significant change in the HIPAA standard,
which now enables a dentist to include a diagnosis
code (ICD-9-CM) when needed on a claim. The
downloadable version of the ADA Dental Claim Form
allows immediate access and requires no shipping. Not
for online use.
J430 8½" x 11"
100 per pad
J430D Downloadable PDF
J431 8½" x 11" Two-part carbonless
J432 8½" x 11" Bond stock
J433 Tractor Feed
100 per pack
250 per pack
250 per pack
J434 Bond in Red Ink
100 per pad
MEMBER
RETAIL
J430
$5.00
$7.50
J430D
$19.95
$29.95
J431
$8.00
$12.00
J432
$20.00
$30.00
J433
$20.00
$30.00
J434
$5.00
$7.50
J430
ADA heAlTh hISTorY form
This edition of the ADA Health History Form reflects
the most recent AHA premedication guidelines.
Clear two-sided layout and simple wording make
form completion easy. Includes questions related to
intravenous bisphosphonates and alendronates.
Also available as a downloadable version for posting
on practice websites. Just download the PDF form
and print — no shipping or handling charges! Or link to
the document from your practice's website and give
patients the option to fill it out before they visit.
S500 8½" x 11"
100 per pad
English
S501 8½" x 11"
100 per pad
Spanish
S500D Downloadable PDF
English
S501D Downloadable PDF
Spanish
MEMBER
RETAIL
S500
$6.50
$9.75
S501
$6.50
$9.75
S500D
$19.95
$29.95
S501D
$19.95
$29.95
S500
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