2012 ADA-Approved Claim Forms - Patterson Office Supplies

The 2012 form has been revised to incorporate a significant change in the HIPAA standard, which now enables a dentist to include a diagnosis code (ICD-9-CM) when needed on a claim.
Personalized forms allow for office/doctor’s information to be added in boxes 48-52A and 54-58.
If in doubt about the correct ID number to use, please consult your carrier for information. You must provide us with the correct information.
ADA Dental Claim Form is reproduced and distributed by Patterson Office Supplies under license from the American Dental Association.
Title/Description
Patterson Item #
Mfg Item #
Price
Qty
2012 ADA-Approved Claim Forms, 2-Part Carbonless Sets, Nonpersonalized, 8-1/2" W x 11" H, 500/Pkg
2012 ADA-Approved Claim Forms, 2-Part Carbonless Sets, Personalized, 8-1/2" W x 11" H, 500/Pkg
2012 ADA-Approved Claim Forms, Single-Sheet Bond/Laser Compatible, Nonpadded, Nonpersonalized, 8-1/2" W x 11" H, 500/Pkg
2012 ADA-Approved Claim Forms, Single-Sheet Bond/Laser Compatible, Nonpadded, Personalized, 8-1/2" W x 11" H, 500/Pkg
2012 ADA-Approved Claim Forms, Single-Sheet Carbonless, Nonpersonalized, 8-1/2" W x 11" H, 100 Sheets/Pad, 5 Pads/Pkg
2012 ADA-Approved Claim Forms, Single-Sheet Carbonless, Personalized, 8-1/2" W x 11" H, 100 Sheets/Pad, 5 Pads/Pkg
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Additional Information
Schedule 2 and 2N
Schedule 3, 3N, 4 and 5
List 1
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