S500
J430
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
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.
MEMBER RETAIL
J430 8½" x 11", 100 per pad $6.50 $9.75
J430D Downloadable PDF $19.95 $29.95
J431 8½" x 11"
Two-part carbonless
100 per pack
$8.00 $12.00
J432 8½" x 11", Bond Stock
250 per pack
$20.00 $30.00
J433 Tractor Feed, 250 per pack $20.00 $30.00
J434 Bond in Red Ink
100 per pad
$6.50 $9.75
ADA HEALTH HISTORY FORM
Clear two-sided layout and simple wording make
form completion easy. Includes questions related to
intravenous bisphosphonates and alendronates, and
reflects the most recent AHA premedication guidelines.
Also available as a download 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.
MEMBER RETAIL
S500 English, 8½" x 11"
100 per pad
$6.50 $9.75
S501 Spanish, 8½" x 11"
100 per pad
$6.50 $9.75
S500D English, Downloadable PDF $19.95 $29.95
S501D Spanish, Downloadable PDF $19.95 $29.95
O R D E R O N L I N E : A D A C ATA L O G . O R G 69
