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Get Ain 320 Dental Form

Date service performed Procedure number Fee For administrative use only Day Year 32. Remarks for unusual services I hereby certify that the procedures as indicated by date have been completed Total fee charged Date Signed dentist FORM APPROVED BY THE COUNCIL ON DENTAL CARE PROGRAMS OF THE ADA 1975 ADS 75 AIN-320 Rev.10/99 An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of .

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