Get ADA J515 2006-2023
Ccident Occupational illness / injury X Radiograph(s) ECF 40. Is Treatment for Orthodontics? No (Skip 41-42) X 39. Number of Enclosures (00 to 99) Other accident 47. Auto Accident State 46. Date of Accident (MM/DD/CCYY) BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting TREATING DENTIST AND TREATMENT LOCATION INFORMATION 48. Name, Address, City, State, Zip Code 53. I hereby certify that the procedures as indicated by date are in progress (for.
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