_ADA Forms-1
_OReports-1
_OScheduler-1
1 - Ins Type
1 - Patients Name [last, first, mi]
1- Type of Transaction
10 - Other Attachments
10a through c - Is Patient's Condition Related to:
10d - Reserved for Local Use
11 - Accident/Injury?
11 - Employment Related?
11 - Insured's Policy Group or FECA Number
11a - Insured's Date of Birth
11b - Employer's Date of Birth
11c - Insurance Plan Name or Program Name
11d - Is there another Health Benefit Plan?
12 - Eligibility Pending? TAR ONLY
12 - Release of Medical Information Signature
12 through 17 - Primary Subscriber Information
13 - Other Dental Coverage?
13 - Payment Authorization Signature
14 - Date of Current: Illness, Injury or Pregnancy
14 - Medicare Dental Coverage?
15 - If Patient has had same or similar illness
15 - Retroactive Eligibility?
16 - CHDP
16 - Dates Patient unable to work in current occupation
17 - CCS
17 and 17a- Name of Referring Physician or Other Source
18 - Hospitalization Dates Related to Current Services
18 - Maxillofacial - Orthodontic
18 through 23 - Patient Information
19 - Billing Provider Name
19 - Reserved for Local Use
1a - Insureds ID Number
2 - Patient's Name
2 - Patients Social Security #
2 - Predetermination/Preauthorization Number
20 - Billing Provider Number
20 - Outside Lab?
21 - Billing Provider Address/Phone
21 - Diagnosis or nature of illness
22 - Place of Service
22. Medicaid Resubmission Number
23 - Prior Authorization Number
23 - Proof of Elgibility
24 - Examination and Treatment
24 through 31 - Record of Services Provided
24a - Date(s) of Service
24b - Place of Service
24c - Type of Service
24d - Procedures, Services or Supplies
24e - Diagnosis Code
24f - Charges
24g - Days or Units
24h through k - EPSDT Family Plan, EMG, COB and Reserved for Local Use
25 - Federal Tax ID Number
25 - Tooth Identification Chart
26 - Patient's Account Number
26 - Tooth # or Letter; Arch; Quadrant
27 - Accept Assignment
27 - Tooth Surfaces
28 - Description of Service
28 - Total Charges
29 - Amount Paid
29 - Date Service Performed
3 - Name, Address, City, State, Zip Code
3 - Patient's Birth Date
3 - Patients Sex
30 - Balance Due
30 - Quantity
31 - Procedure Numbers
31 - Signature of Physician or Supplier
32 - Fee
32 - Name and Address of Facility Where Services were Rendered
32 - Other Fees
33 - Physician's, Supplier's Billing Name, Address, PIN# and GRP#
33 - Total Fees
33 - Treating Medi-CAL Provider #
34 - Comments
34 - Missing Teeth Information
35 - Remarks
35 - Total Fee Charged
36 - Patient Consent
36 - Patient Share of Cost Amount
37 - Insured's Signature
37 - Other Coverage Amount
38 - Date Billed
38 - Place of Treatment
39 - Number of Enclosures (00 to 99)
39 - Signature Block
4 - Insured's Name
4 - Other Dental or Medical Coverage?
4 - Patients Birth Date
40 - Is Treatment for Orthodontics?
41 - Date Appliance Placed
42 - Months of Treatment Remaining
43 and 44 - Replacement of Prothesis? Date of Prior Placement
45 through 47 - Treatment Resulting from
48 through 52 - Billing Dentist or Dental Entity
5 - Patient MediCAL ID#
5 - Patient's Address
5 through 11 - Other Coverage Information
53 - Certification
54 and 55 - Provider ID# and License Number
54 and 55 - Provider NPI and License Number
56 and 57- Address, placePlaceTypeCity PlaceTypeState, Zip Code and Phone Number
56, 56a and 57- Address, placePlaceTypeCity PlaceTypeState, Zip Code and Phone Number
58 - Additional Provider ID
58 - Treating Provider Specialty
6 - Patients Address
6 - Patient's Relationship to Insured
7 - Insured's Address
7 - Patient Dental Record#
8 - Patient Status
8 - Referring Provider#
9 - Other Insured's Name
9 - Radiographs Attached?
9a - Other Insured's Policy or Group Number
9b - Other Insured's Date of Birth
9c - Employer's Name or School Name
9d - Insurance Plan Name or Program Name
A Word About HELP
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