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ADA 2002/2004 Form

 

 

More:

 

1- Type of Transaction

2 - Predetermination/Preauthorization Number

3 - Name, Address, City, State, Zip Code

4 - Other Dental or Medical Coverage?

5 through 11 - Other Coverage Information

12 through 17 - Primary Subscriber Information

18 through 23 - Patient Information

24 through 31 - Record of Services Provided

32 - Other Fees

33 - Total Fees

34 - Missing Teeth Information

35 - Remarks

36 - Patient Consent

37 - Insured's Signature

38 - Place of Treatment

39 - Number of Enclosures (00 to 99)

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

53 - Certification

54 and 55 - Provider ID# and License Number

56 and 57- Address, placePlaceTypeCity PlaceTypeState, Zip Code and Phone Number

58 - Treating Provider Specialty