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Get ADA J430 2012-2024

Or dental entity. X _____________________________________________________________________________ Subscriber Signature Date Billing Dentist or Dental Entity (Leave blank if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber.) n 39. Enclosures (Y or N) (e.g. 11=office; 22=O/P Hospital) (Use “Place of Service Codes for Professional Claims”) 40. Is Treatment for Orthodontics? No (Skip 41-42) 42. Months of Treatment Remaining 41. Date Applia.

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