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Specification
Brand : NextDayLabels
BulletPoint : AAAA-ZZZZ Dividers
BulletPoint1 : Comprehensive Form: This ADA American Dental Association Dental Claim Form is a comprehensive document for submitting dental claims and treatment information. Pack of 250 Sheets
BulletPoint2 : Detailed Sections: The form includes sections for patient information, policyholder/subscriber details, dental benefit plan information, and a record of services provided.
BulletPoint3 : Coding Support: It allows for entering diagnostic codes, treatment codes, and other relevant coding for proper claim processing.
BulletPoint4 : Authorization Segment: There is a dedicated section for obtaining authorizations and signatures from the patient or policyholder.
BulletPoint5 : Dentist Information: The form provides fields to enter the treating dentist's name, address, license number, and other relevant details, Made in the USA by Next Day Labels TM
Color : Yellow
ControlMethod : touch
CustomerPackageType : Standard Packaging
ExternallyAssignedProductIdentifier : 7605893487889
ExternallyAssignedProductIdentifier1 : 520361224544
ExternallyAssignedProductIdentifier2 : 0520361224544
ExternallyAssignedProductIdentifier3 : 810148902544
ExternallyAssignedProductIdentifier4 : 688474840317
IncludedComponents : Automatic Seed Counter Machine, S/M Sample Plate，L Sample Plate, Accessories, Manual
ItemName : ADA Dental Claim Insurance Claim Forms, 8-1/2" X 11" Letter Size for Laser or Ink Jet Printers (Pack of 250 Sheets)
ItemPackageDimensions_Height : 40.7 centimeters
ItemPackageDimensions_Length : 22.6 centimeters
ItemPackageDimensions_Width : 28.6 centimeters
ItemPackageQuantity : 1
ItemTypeKeyword : business-claim-forms
Manufacturer : NextDayLabels
Material : Polypropylene or similar plastic
Material1 : Metal
Material2 : Metal
Material3 : Metal
Material4 : Metal
Material5 : Metal
ModelNumber : V-519
NumberOfDividers : 26
NumberOfItems : 1
PaperSize : Letter
PartNumber : NDL-ADA forms
ProductDescription : This American Dental Association (ADA) dental claim form is an essential document for dental professionals and patients alike. It serves as a standardized template for submitting claims to insurance companies for reimbursement of dental services rendered. The form captures crucial information such as patient details, dental benefit plan information, services provided, diagnosis codes, treatment details, and billing information. With designated sections for authorizations and ancillary claim/treatment information, this comprehensive form streamlines the claims process, ensuring accurate and efficient communication between dental providers and insurance carriers. Measuring 8.5 x 11 inches, this form can be easily printed and filled out by hand or electronically, facilitating seamless record-keeping and claims submission within the dental industry. Pack contains 250 Sheets, Made in the USA by Next Day Labels TM
ProductSiteLaunchDate : 2024-11-13T21:33:13.088Z
Size : Pack of 250 Sheets
Style : 851-875
SupplierDeclaredDgHzRegulation : not_applicable
SupplierDeclaredHasProductIdentifierExemption : 1
UnitCount : 1
UnspscCode : 53130000
WarrantyDescription : 1