ADA J400 Form


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What is ADA J400 Form?

The ADA dental claim form J400 was created by ADA specialists for professionals who want to report the dental plan services to the dental benefit plan of their patients. Both payers and dentists can use the form. Association welcomes the use of this form and tries to simplify it for everyone who needs to fill it out. There were several updates to the document since it was originally created. This document requires information on the insurance company that offers the benefit plan and information on the policyholder as well. If the policy covers a wide range of dental and medical procedures, the respondent who fills out the document has to provide information about it. You also have to be specific about all the services that were provided.

If the patient misses teeth, the specialist has to name them and be specific about which teeth are missing and the treatment that is proposed. You can’t fill out this ADA J400 form by yourself if you don’t own the appropriate information. The form must be accepted and read by ADA.

ADA J400 Form on PDFLiner

What I need the ADA J400 Form for?

  • The ADA J400 claim form is mainly required by the patient who needs to receive benefits from the insurance company that provides dental benefits and health care. This claim must be left after the patient received treatment and knows the diagnosis so ADA can make a decision about the case;

  • A dental professional has to provide ADA dental form J400 to the ADA on behalf of the patient who asked for the help. If the patient has the insurance policy on the dental benefit, the information must be filled and the payment on the dental policy received.

  • The J400 ADA dental claim form is sent to the American Dental Association with detailed information on the insurance case for each specific patient.

How to fill out ADA J400 Form?

The document ADA claim form J400 can be easily found on American Dental Association’s official website. Moreover, each dental clinic or private professional that belongs to the Association can also provide the form. If you have not found it, you can Google and find it in no time. Yet, no forms can be filled out while you are online. PDFLiner offers to complete ADA J400 form PDF with a wide range of tools it provides to everyone. You can fill it out once you enter it. After that, save it to the device, print it, and hand it to the other party. You may also send it via email. The document is not that complicated but it must be filled by a professional who owns appropriate information about the health of the teeth. Here is what you need to include in ADA 2006 J400 claim form:

  1. Pick the type of transaction you provide and put the tick in the appropriate box;

  2. Share the information on the policyholder, including name, date of birth, ID, plant, and employer name;

  3. Provide information on the insurance company, including the name, and address;

  4. Provide the information on the coverage of the medical insurance you have;

  5. Provide the patient information;

  6. Provide information on the dental problem patient complaints;

  7. Share information on the treatment that was or must be received;

  8. Put the patient’s information.

Organizations that work with ADA J400 Form

  • American Dental Association;

  • Any clinic that works with ADA.

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Fillable online ADA J400 Form
(4.5 / 5) 76 votes
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