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Type into form fields
Enter information directly into the corresponding areas of the dental claim form.
Dental claim form
ADA Dental Claim fillable PDF
Type dental claim information into the form, save completed copies, and print the full form and data together.
$59.95one-time product purchase
Fill in the dental claim form and print it on plain paper.
A straightforward way to prepare dental claims
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Save separate copies
Create a new saved PDF for each completed claim.
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Print the full form
Print the form and typed information together using black ink.
Before ordering
This product is a fillable PDF, not the CMS-1500 or UB-04 Windows program. Use a current PDF reader that supports fillable form fields and saving completed copies.
Store completed claim files according to your organization’s privacy and data-security procedures.
Frequently asked questions
Can I save completed dental claim forms?
Yes. Save each completed PDF with a filename that identifies the claim or patient according to your organization’s privacy procedures.
Does it print the form and data together?
Yes. The completed form can be printed on plain paper with the form and typed information together.
How many claims can I create?
The fillable PDF can be reused to prepare multiple claim files. Save each completed claim as a separate copy.