Instructions For Completing The ADA J515 Dental Claim Form For Texas Workers' Compensation Claims
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FAQ
This information applies to the entire transaction. 1. Type of Transaction: There are three boxes that may apply to this submission. If services have been performed, mark the ?Statement of Actual Services? box.
Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code: Enter the complete name, address and zip code of the patient. 21. Date of Birth (MM/DD/CCYY): A total of eight digits are required in this field; two for the month, two for the day of the month, and four for the year of birth of the patient.
American Dental Association (ADA)
3. Box 26: Tooth System This system is numbering 1-32 for permanent dentition and lettering A-T for primary dentition. This is also referred to as the American system. ?JO? is used when designating teeth using the Internation Standards Organization (ISO) System.
All dentists and dental students, regardless of membership status, have a nine-digit ADA number, which functions as your User ID. If you are an ADA member dentist or dental student, you can use either your nine-digit ADA member number or your primary email on file with the ADA as your User ID.
An employer is not allowed to fire an employee who makes a claim for worker's compensation. They cannot fire a person because of a disability either. Employers are prohibited from firing a person from their job if the disability affected one's ability to perform the job and whenever they are on restricted duty.
The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. ADA policy promotes use and acceptance of the most current version of the ADA Dental Claim Form by dentists and payers.
Call 800-252-7031, option 1. Workers' compensation is an insurance program managed by the State of Texas.
