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Starting January 1 2024 providers and dental industry partners will see crucial updates designed to streamline dental claims processing. Developed in conjunction with all the governing agencies including the National Uniform Claim Committee (NUCC) the National Uniform Billing Committee (NUBC) the CMS Centers for Medicare and Medicaid Services the Health and Human Services Agency and the American Hospital Association. Forms adhere to strict printing standards that govern the layout paper and ink. 100% compliant to meet ADA guidelines. The following materials are prepared by ADA Practice Institute staff with contributions from the ADA Council on Dental Benefit Programs and other internal and external knowledge experts. The 2024 version provides new spaces for reporting data that can expedite timely and accurate claim reimbursement. It is now possible to clearly identify claims for services delivered by a locum tenens dentist one who is standing in for another who is away from the practice for a short time. The form also supports reporting an identifier known as Payer ID that when available uniquely identifies the third-party payer receiving the claim.|Forms conform to the Health Insurance Portability and Accountability Act (HIPAA)|Forms provide a common format for reporting dental services to a patient's dental benefit plan|ADA policy promotes use and acceptance latest version ADA Dental Claim Forms by dentists and payers|ComplyRight Dental Claim Forms allow healthcare providers to bill a patient's insurance company for reimbursement of dental claims. (4)

At the initial visit obtain a medical history as well as pertinent personal financial and insurance information all on one form. Features four medical history updates on back.|Type of form: Dental registration and medical history form|250 per pack|Size: 8 1/2 x 11|Binding type: Loose|Number of parts: 1|Printed on white ledger stock (1)

Check list of services to be included in your treatment plan.|100 sheets per package|Size: 8-1/2 x 11|Form Printed on 1 Side (1)

Comprehensive form gathers complete insurance information making it easier for you to process claims|Friendly happy teeth design welcomes patients|Printed in 2-color on two sides on 24-lb. white bond paper|250 sheets/pack|Size: 8-1/2x11 (1)

Comprehensive form gathers complete insurance information making it easier for you to process claims|Silhouetted toothbrush design welcomes patients|Printed in 1-color on two sides on 24-lb. white bond paper|250 sheets/pack|Size: 8-1/2x11 (1)

HIPAA compliant insurance authorization|Help ensure reimbursement and improve risk management|Collects printed name and relationship to patient|Medication lists requests correlating diagnosis|Screens for artificial heart valves artificial joints heart murmur mitral valve prolapse and pacemaker|250 sheets per film wrapped pack|Size: 8-1/2x11 (1)

HIPAA-compliant insurance authorization.|Collects printed name and relationship to patient|Medication list requests correlating diagnosis|Screens for artificial heart valves artificial joints heart|Size: 8-1/2x11 (1)

Ideal for practices that prefer not to record fees on their treatment notes. Form includes basic patient information. Two-sided with back of form ruled. Printed flip-up style. Package of 250. Size 8-1/2x11.|Ideal for practices that prefer not to record fees on their treatment notes|Form includes basic patient information|Two-sided with back of form ruled|Printed flip-up style|Package of 250|Size: 8-1/2 x 11 (1)

Includes arch diagram for documenting bridge work and removable partials. Plenty of room to record a full exam and dental history. Has space for medical alerts and treatment summary. Printed one side in blue ink on 24-lb. bond. 250 per package. Size: 8-1/2x11.|Form size: 8-1/2x11|2-hole punched on top|5-hole punched on the left side (1)

Keep your dental records organized with our comprehensive tooth treatment notes. Each pack contains 250 loose sheets sized 8 1/2 x 11 featuring columns for date tooth number surface treatment notes initials and fee plus ample space for additiona|l notes. Printed on both sides with optional hole punching these notes are perfect for detailed record-keeping.|Type of form: Treatment note|250 per pack|Size: 8 1/2 x 11|Binding type: Loose|Number of parts: 1|Feature columns for date tooth number tooth surface treatment notes initials and fee plus generous space for your notes|Printed same on both sides (1)

Organize dental records efficiently with our tooth treatment chart and diagram notes. Each pack contains 250 loose sheets sized 8 1/2 x 11 printed on white paper with easy-to-use tooth diagrams and columns for date tooth number surface treatment notes initials and fee. With generous space for additional notes and optional hole punching these charts are perfect for detailed dental exams.|Set per pack (uom): 250 per pack|Size: 8 1/2 x 11|Dental exam chart format|Binding type: Loose|Number of parts: 1|Paper color: White|Printed same on both sides hole punching options available|Has easy-to-use tooth diagrams and columns for date tooth number tooth surface treatment notes initials and fee plus generous space for your notes|250 notes per pack|No punch options (1)

Provides your patient complete information about their treatment and its risks|Obtains written consent for your records|Just check off applicable conditions; patient reads explanation initials and signs|Printed one side on 24-lb. stock|2-hole punched at the top|250 per package|Size: 8-1/2x11 (1)

Sets a friendly welcome tone for new patients. Gathers complete personal information dental history and insurance information plus assignment and release for account setup. Printed both sides on 24-lb. bond. 250 forms per package. Size: 8-1/2x11. (1)

Size: 8 1/2 x 11|Paper color: White|Number of parts: 1|Binding type: Loose|Give your patients complete information about their treatment and obtain written consent for your own records|Convenient form allows you to just check off the applicable information|Bilingual form - back side is in Spanish|Printed on two sides in black ink on white 24 lbs. bond stock|This convenient form allows you to just check off the applicable information|Your patient reads the explanation initials the appropriate sections and signs the bottom|Packages of 250 (1)

Streamline patient information collection with our dental registration form. This easy-to-fill-out form features individually numbered sections for comprehensive data gathering including patient information insurance details and medical history. Printed in purple ink on 24 lb. white bond paper the two-sided form is 2-hole punched at the top for convenience. Each pack contains 250 forms sized 8 1/2 x 11 perfect for thorough dental registration and history documentation.|Form allows you to gather complete information from patients|Simple to fill out with individually numbered sections|Includes sections on patient information insurance history and more|Head to toe dental registration and history form|2-sided form is printed top-to-bottom in purple ink on 24 lb. white bond paper|2-hole punched at the top|250 per package|Size: 8-1/2x11 (1)

Type of form: Dental registration and history form|250 per pack|Size: 8 1/2 x 11|Paper weight: 20 lbs.|Number of parts: 1|Obtain a medical history and personal financial and insurance information all on one form|Has special sections for parent information insurance authorization and 2 medical history updates|Printed on 20 lbs. bond (1)

Use this form to keep up with any important changes in your patients' health since their last visit. Includes space for up to five updates and can be filled in by patient or staff. Printed one side in blue ink on 24-lb. bond. 250 per package. Size: 8-1/2x11.|Type of form: Dental history update form|250 per pack|Size: 8 1/2 x 11|Paper weight: 24 lbs.|Binding type: Loose|Number of parts: 1|Use this form to keep up with any important changes in your patients' health since their last visit|Includes space for up to five updates and can be filled in by patient or staff|Printed on 24 lbs. white ledger stock (1)

User-friendly form has an easy-to-follow format and thorough questions. Includes complete personal and insurance information and assignment and release for easy account set up|Type of form: Dental registration form|250 per pack|Size: 8 1/2 x 11|Paper weight: 24 lbs.|Binding type: Loose|Number of parts: 1|Printed both sides on 24 lbs. bond in blue and black ink (1)

Dental exam chart format. Detailed form illustrated with anatomical tooth graphics for permanent and deciduous teeth. Columns for date tooth number surface ADA code fee|Binding type: Loose|Number of parts: 1|Paper color: White|Printed same on both sides hole punching options available|24 lbs. ledger stock paper|Columns for date tooth number surface ADA code fee and more|Printed same on both sides|250 forms per pack|Size: 8-1/2 x 11 (1)

For use in patient charts|8-1/2 W x 11 L|White 20# text stock; printed in black ink|250 sheets per pack|2-sided Form HIPAA compliant|At the initial visit obtain a medical history as well as pertinent personal financial and insurance information all on one form. (1)

For use in patient charts|8-1/2 W x 11 L|White 20# text stock; printed in black ink|250 sheets per pack|2-sided sheets with columns for date tooth number tooth surface treatment notes and more|Use these simple progress notes to track chronological communications and dental notes effectively in any patient chart! (1)

For use in providing estimates and treatment plans|8-1/2 W x 11 L|2-part white/canary carbonless; printed in black ink|250 sheets per pack|Features mouth illustration at bottom and comments section|This 2-part form allows you to give patients a thorough explanation of treatment needs. (1)

Includes complete personal and insurance information and assignment and release for easy account set up|8-1/2 W x 11 L|White 24# bond stock pre-printed in black and blue ink|250 sheets per pack|Total of 6 sections printed on the front and back|No custom imprint customization allows for a choice of hole punch locations|User-friendly form has an easy-to-follow format and thorough questions. (1)

Use for patient care instructions|8-1/2 W x 11 L|White 20# text stock; printed in black ink|100 sheets per pad order in quantities of 5 pads|Padded at the top|Bilingual form instructs both your English and Spanish speaking patients about proper follow-up care after treatment extractions periodontal treatment and crown or bridge treatment! (1)

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Starting January 1 2024 providers and dental industry partners will see crucial updates designed to streamline dental claims processing. Developed in conjunction with all the governing agencies including the National Uniform Claim Committee (NUCC) the National Uniform Billing Committee (NUBC) the CMS Centers for Medicare and Medicaid Services the Health and Human Services Agency and the American Hospital Association. Forms adhere to strict printing standards that govern the layout paper and ink. 100% compliant to meet ADA guidelines. The following materials are prepared by ADA Practice Institute staff with contributions from the ADA Council on Dental Benefit Programs and other internal and external knowledge experts. The 2024 version provides new spaces for reporting data that can expedite timely and accurate claim reimbursement. It is now possible to clearly identify claims for services delivered by a locum tenens dentist one who is standing in for another who is away from the practice for a short time. The form also supports reporting an identifier known as Payer ID that when available uniquely identifies the third-party payer receiving the claim.|Forms conform to the Health Insurance Portability and Accountability Act (HIPAA)|Forms provide a common format for reporting dental services to a patient's dental benefit plan|ADA policy promotes use and acceptance latest version ADA Dental Claim Forms by dentists and payers|ComplyRight Dental Claim Forms allow healthcare providers to bill a patient's insurance company for reimbursement of dental claims. (4)
At the initial visit obtain a medical history as well as pertinent personal financial and insurance information all on one form. Features four medical history updates on back.|Type of form: Dental registration and medical history form|250 per pack|Size: 8 1/2 x 11|Binding type: Loose|Number of parts: 1|Printed on white ledger stock (1)
Check list of services to be included in your treatment plan.|100 sheets per package|Size: 8-1/2 x 11|Form Printed on 1 Side (1)
Comprehensive form gathers complete insurance information making it easier for you to process claims|Friendly happy teeth design welcomes patients|Printed in 2-color on two sides on 24-lb. white bond paper|250 sheets/pack|Size: 8-1/2x11 (1)
Comprehensive form gathers complete insurance information making it easier for you to process claims|Silhouetted toothbrush design welcomes patients|Printed in 1-color on two sides on 24-lb. white bond paper|250 sheets/pack|Size: 8-1/2x11 (1)
HIPAA compliant insurance authorization|Help ensure reimbursement and improve risk management|Collects printed name and relationship to patient|Medication lists requests correlating diagnosis|Screens for artificial heart valves artificial joints heart murmur mitral valve prolapse and pacemaker|250 sheets per film wrapped pack|Size: 8-1/2x11 (1)
HIPAA compliant insurance authorization|Help ensure reimbursement and improve risk management|Collects printed name and relationship to patient|Medication lists requests correlating diagnosis|Screens for artificial heart valves artificial joints heart murmur mitral valve prolapse and pacemaker|250 sheets per film wrapped pack|Size: 8-1/2x11|To view an enlarged sample of this form Click Here (1)
HIPAA-compliant insurance authorization.|Collects printed name and relationship to patient|Medication list requests correlating diagnosis|Screens for artificial heart valves artificial joints heart|Size: 8-1/2x11 (1)
Ideal for practices that prefer not to record fees on their treatment notes. Form includes basic patient information. Two-sided with back of form ruled. Printed flip-up style. Package of 250. Size 8-1/2x11.|Ideal for practices that prefer not to record fees on their treatment notes|Form includes basic patient information|Two-sided with back of form ruled|Printed flip-up style|Package of 250|Size: 8-1/2 x 11 (1)
Includes arch diagram for documenting bridge work and removable partials. Plenty of room to record a full exam and dental history. Has space for medical alerts and treatment summary. Printed one side in blue ink on 24-lb. bond. 250 per package. Size: 8-1/2x11.|Form size: 8-1/2x11|2-hole punched on top|5-hole punched on the left side (1)
Keep your dental records organized with our comprehensive tooth treatment notes. Each pack contains 250 loose sheets sized 8 1/2 x 11 featuring columns for date tooth number surface treatment notes initials and fee plus ample space for additiona|l notes. Printed on both sides with optional hole punching these notes are perfect for detailed record-keeping.|Type of form: Treatment note|250 per pack|Size: 8 1/2 x 11|Binding type: Loose|Number of parts: 1|Feature columns for date tooth number tooth surface treatment notes initials and fee plus generous space for your notes|Printed same on both sides (1)
Organize dental records efficiently with our tooth treatment chart and diagram notes. Each pack contains 250 loose sheets sized 8 1/2 x 11 printed on white paper with easy-to-use tooth diagrams and columns for date tooth number surface treatment notes initials and fee. With generous space for additional notes and optional hole punching these charts are perfect for detailed dental exams.|Set per pack (uom): 250 per pack|Size: 8 1/2 x 11|Dental exam chart format|Binding type: Loose|Number of parts: 1|Paper color: White|Printed same on both sides hole punching options available|Has easy-to-use tooth diagrams and columns for date tooth number tooth surface treatment notes initials and fee plus generous space for your notes|250 notes per pack|No punch options (1)
Provides your patient complete information about their treatment and its risks|Obtains written consent for your records|Just check off applicable conditions; patient reads explanation initials and signs|Printed one side on 24-lb. stock|2-hole punched at the top|250 per package|Size: 8-1/2x11 (1)
Sets a friendly welcome tone for new patients. Gathers complete personal information dental history and insurance information plus assignment and release for account setup. Printed both sides on 24-lb. bond. 250 forms per package. Size: 8-1/2x11. (1)
Size: 8 1/2 x 11|Paper color: White|Number of parts: 1|Binding type: Loose|Give your patients complete information about their treatment and obtain written consent for your own records|Convenient form allows you to just check off the applicable information|Bilingual form - back side is in Spanish|Printed on two sides in black ink on white 24 lbs. bond stock|This convenient form allows you to just check off the applicable information|Your patient reads the explanation initials the appropriate sections and signs the bottom|Packages of 250 (1)
Streamline patient information collection with our dental registration form. This easy-to-fill-out form features individually numbered sections for comprehensive data gathering including patient information insurance details and medical history. Printed in purple ink on 24 lb. white bond paper the two-sided form is 2-hole punched at the top for convenience. Each pack contains 250 forms sized 8 1/2 x 11 perfect for thorough dental registration and history documentation.|Form allows you to gather complete information from patients|Simple to fill out with individually numbered sections|Includes sections on patient information insurance history and more|Head to toe dental registration and history form|2-sided form is printed top-to-bottom in purple ink on 24 lb. white bond paper|2-hole punched at the top|250 per package|Size: 8-1/2x11 (1)
Type of form: Dental registration and history form|250 per pack|Size: 8 1/2 x 11|Paper weight: 20 lbs.|Number of parts: 1|Obtain a medical history and personal financial and insurance information all on one form|Has special sections for parent information insurance authorization and 2 medical history updates|Printed on 20 lbs. bond (1)
Type of form: Registration and history form|250 per pack|Size: 8 1/2 x 11|Binding type: Loose|Design: Tooth Character|Number of parts: 1|Gathers complete personal information dental history and insurance information plus assignment and release for account setup|Printed both sides on 24 lbs. bond in teal ink (1)
Type of form: Registration and history form|250 per pack|Size: 8 1/2 x 11|Binding type: Loose|Design: Welcome Toothbrush Teal|Number of parts: 1|Gathers complete personal information dental history and insurance information plus assignment and release for account setup|Printed both sides on 24 lbs. bond in teal ink (1)
Type of form: Registration and treatment form|250 per pack|Size: 8 1/2 x 11|Paper weight: 60 lbs.|Binding type: Loose|Number of parts: 1|Streamline your documentation with this comprehensive form|Combines patient registration dental/medical history examination/treatment and treatment notes in one 4-page document|Offset stock (1)
Use this form to keep up with any important changes in your patients' health since their last visit. Includes space for up to five updates and can be filled in by patient or staff. Printed one side in blue ink on 24-lb. bond. 250 per package. Size: 8-1/2x11.|Type of form: Dental history update form|250 per pack|Size: 8 1/2 x 11|Paper weight: 24 lbs.|Binding type: Loose|Number of parts: 1|Use this form to keep up with any important changes in your patients' health since their last visit|Includes space for up to five updates and can be filled in by patient or staff|Printed on 24 lbs. white ledger stock (1)
User-friendly form has an easy-to-follow format and thorough questions. Includes complete personal and insurance information and assignment and release for easy account set up|Type of form: Dental registration form|250 per pack|Size: 8 1/2 x 11|Paper weight: 24 lbs.|Binding type: Loose|Number of parts: 1|Printed both sides on 24 lbs. bond in blue and black ink (1)
Dental exam chart format. Detailed form illustrated with anatomical tooth graphics for permanent and deciduous teeth. Columns for date tooth number surface ADA code fee|Binding type: Loose|Number of parts: 1|Paper color: White|Printed same on both sides hole punching options available|24 lbs. ledger stock paper|Columns for date tooth number surface ADA code fee and more|Printed same on both sides|250 forms per pack|Size: 8-1/2 x 11 (1)
For use in patient charts|8-1/2 W x 11 L|White 20# text stock; printed in black ink|250 sheets per pack|2-sided Form HIPAA compliant|At the initial visit obtain a medical history as well as pertinent personal financial and insurance information all on one form. (1)
For use in patient charts|8-1/2 W x 11 L|White 20# text stock; printed in black ink|250 sheets per pack|2-sided sheets with columns for date tooth number tooth surface treatment notes and more|Use these simple progress notes to track chronological communications and dental notes effectively in any patient chart! (1)
For use in providing estimates and treatment plans|8-1/2 W x 11 L|2-part white/canary carbonless; printed in black ink|250 sheets per pack|Features mouth illustration at bottom and comments section|This 2-part form allows you to give patients a thorough explanation of treatment needs. (1)
Includes complete personal and insurance information and assignment and release for easy account set up|8-1/2 W x 11 L|White 24# bond stock pre-printed in black and blue ink|250 sheets per pack|Total of 6 sections printed on the front and back|No custom imprint customization allows for a choice of hole punch locations|User-friendly form has an easy-to-follow format and thorough questions. (1)
Use for patient care instructions|8-1/2 W x 11 L|White 20# text stock; printed in black ink|100 sheets per pad order in quantities of 5 pads|Padded at the top|Bilingual form instructs both your English and Spanish speaking patients about proper follow-up care after treatment extractions periodontal treatment and crown or bridge treatment! (1)

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Medical Arts Press® Registration Form Featuring Updates Section/Blue Wave

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Medical Arts Press® Registration Form Featuring Updates Section/Blue Wave

Item #: 901-33018

HIPAA compliant insurance authorization

Help ensure reimbursement and improve risk management

Collects printed name and relationship to patient

$20.59

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Custom Carbonless 2-Part Dental Diagnosis and Estimate Forms, 8-1/2 x 11, 250 Sheets per Pack

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Custom Carbonless 2-Part Dental Diagnosis and Estimate Forms, 8-1/2" x 11", 250 Sheets per Pack

Item #: 901-QFN102621R

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For use in providing estimates and treatment plans

8-1/2" W x 11" L

2-part, white/canary, carbonless; printed in black ink

$85.99

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($0.34/EACH)

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Custom Dental After-Treatment Instruction Forms, 8-1/2 x 11, 100 Sheets per Pad

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Custom Dental After-Treatment Instruction Forms, 8-1/2" x 11", 100 Sheets per Pad

Item #: 901-QFN105611R

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Use for patient care instructions

8-1/2" W x 11" L

White 20# text stock; printed in black ink

$32.99

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Medical Arts Press Treatment Notes, Tooth #, Non-Imprinted, No Punch, 250/Pack (20560NP)

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Medical Arts Press Treatment Notes, Tooth #, Non-Imprinted, No Punch, 250/Pack (20560NP)

Item #: 901-20560NP

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Item #: 901-20560NP

Type of form: Treatment note

250 per pack

Size: 8 1/2" x 11"

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Medical Arts Press Treatment Notes, Tooth Diagram, Non-Imprinted, No Punch

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Medical Arts Press Treatment Notes, Tooth Diagram, Non-Imprinted, No Punch

Item #: 901-21150NP

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Item #: 901-21150NP

Set per pack (uom): 250 per pack

Size: 8 1/2" x 11"

Dental exam chart format

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Medical Arts Press Dental Treatment Notes, Tooth Chart, 250/Pack (20601RL)

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Medical Arts Press Dental Treatment Notes, Tooth Chart, 250/Pack (20601RL)

Item #: 901-20601NP

Binding type: Loose

Number of parts: 1

Paper color: White

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Custom Treatment Notes, 8-1/2 x 11, 250 Sheets per Pack

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Custom Treatment Notes, 8-1/2" x 11", 250 Sheets per Pack

Item #: 901-QFN105601R

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For use in patient charts

8-1/2" W x 11" L

White 20# text stock; printed in black ink

$104.99

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