Patient Information on the ADA Dental Claim Form

Match the practice record

Use the patient's legal or plan-recognized name, birth date, address or other requested identifiers as supported by the office record and payer information. Avoid copying a family member's data from a prior claim.

Patient versus subscriber

When the patient is a dependent, the subscriber section identifies the policyholder while the patient section identifies the person treated. Check both before printing rather than assuming a shared surname means the records match.

Saved patient records need review

Reusable patient records reduce typing, but addresses, coverage relationships, and plan information can change. A saved record should be treated as a starting point, not proof that every field remains current.

Dental-claim review

• Keep patient information separate from subscriber information; the patient may be a dependent.
• Verify the patient’s name, address, birth date, relationship, and office account data against current records.
• Do not let a prior family member’s information carry into the wrong patient claim.

Sources and verification

Use the ADA source below for the current 2024 Dental Claim Form and completion guidance, together with the dental plan’s requirements.

• American Dental Association: 2024 ADA Dental Claim Form

Related guides

• Dentist and Provider Information on the ADA Dental Claim Form
• What Is the 2024 ADA Dental Claim Form?
• Understanding the Main Sections of the ADA Dental Claim Form