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Web comprehensive ada dental claim form completion instructions are printed in the cdt manual. Web the ada dental claim form provides a common format for reporting dental services to a patient's dental benefit plan. Policyholder/subscriber id (assigned by plan) m f u other coverage (mark. Policyholder/subscriber name (last, first, middle initial, sufix), address, city, state, zip code 13. Web comprehensive.

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Policyholder/subscriber name (last, first, middle initial, sufix), address, city, state, zip code 13. Web comprehensive completion instructions for the ada dental claim form are found in the current version of the cdt manual.