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This information is required when the diagnosis may affect claim adjudication when specific. Web the ada dental claim form was last structurally revised in 2012 to incorporate key data content changes that enables diagnosis code.

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Web comprehensive ada dental claim form completion instructions are printed in the cdt manual. Web this version of the form, front and reverse sides, is illustrated on the next two pages. Web ada american dental association header information i typo of transaction (mark a applicable boxes) dental claim form policyholdewsubscriber. Web to reorder call 800.947.4746 or go online at adacatalog.org.

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