www.SinclairInkSpot.com/DentalForms
Commonly used
dental forms:
ADA J515:
Counter
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Field Number
Name
Instructions for Completion
1a
Dentist’s statement of actual services
Check the box marked “Dentist’s Statement of
Actual Services”.
2
Medicaid Claim
Check this box. “Prior Authorization” field is optional.
3
Carrier Name
Not required
4
Carrier Address
Not required
5
City
Not required
6
State
Not required
7
ZIP
Not required
8
Patient Name (Last, First, MI)
Required field. Enter the client’s last name followed by the first name. Middle initial is optional.
9
Address
Optional field
10
City
Optional field
11
State
Optional field
12
Date of Birth
Optional field
13
Patient Account#
Optional field
14
Sex
Check M for male and F for female
15
Phone Number
Not required
16
ZIP Code
Not required
17
Relationship to subscriber
Not required. If there is other insurance primary coverage for the client, note the information.
18
Employer/School
If there is other primary insurance coverage for the client, note the employer’s name.
19
Subs./Emp ID#SSN#
This is the Client ID Number found on the patient’s plastic card. Enter the patient’s 10-digit
Medicaid ID number.
20
Employer Name
Not required. If there is other primary insurance for the client, note the employer’s name.
21
Group#
Not required. If there is other primary insurance, enter the Group number.
22
Subscriber/Employer Name
Not required. If there is other primary insurance, enter the subscriber/employer name.
23
Address
Not required
24
Phone Number
Not required
25
City
Not required
26
State
Not required
27
ZIP Code
Not required
28
Date of Birth
Not required
29
Marital Status
Not required
Dental Billing Provider Billing Manual
Field Number
Name
Instructions for Completion
30
Sex
Not required
31
Is Patient Covered by Another Plan
If no other plan covers the patient, skip to Field 42.
If Yes, complete Fields 31, 32, 33 and 36. If Yes is selected and the other insurance made a
payment, indicate the payment amount in Field 60–“Payment by other plan.”
32
Policy#
Enter the policy number for the primary policy
33
Other Subscriber’s Name
Enter the name of the policyholder of the primary policy
34
Date of Birth
Not required
35
Sex
Not required
36
Plan/Program Name
Enter the NEIC number for the primary policy
37
Employer/School
Not required
38
Subscriber/Employee Status
Not required
39
Signature
Not required
40
Employer/School
Not required
41
Signature
Not required
42
Name of the Billing Dentist or Dental Entity
Enter the name of the billing dentist or group as it appears on your Medicaid Provider Enrollment
application
43
Phone Number
Enter the provider’s phone number
44
Provider ID#
If part of a Group, enter the 10-digit “performing” dentist’s NPI #.
This number identifies which dentist performed the actual service.
If not part of a Group, leave this field blank and enter the sole practitioner NPI # in Field 45. See
below.
45
Dentist Soc. Sec. Or T.I.N.
This is the field for the Provider’s Group NPI #, OR the sole practitioner NPI# (which serves as both
the performing NPI # and the billing NPI#).
46
Address
Not required
47
Dentist License#
Not required
48
First visit date of current series
Not required
49
Place of treatment
Check the appropriate box
50
City
Not required
51
State
Not required
52
ZIP Code
Not required
53
Radiographs or models
Not required
54
Is treatment for orthodontics?
Not required
55
If prosthesis, is this
Not required
Dental Billing Provider Billing Manual
Field Number
Name
Instructions for Completion
initial placement?
56
Is treatment the result of illness or injury?
Check yes box if applicable
57
Is treatment result of auto/other accident?
Check yes box if applicable
58
Diagnosis Code Index
Not required. Use only ICD-9 codes. Do not use SNODENT codes.
59
Date
Tooth
Surface
Diagnosis
Procedure Code
Quantity
Description
Fee
Enter the date of service in the following format: mm/dd/ccyy.
Enter the Primary or Permanent Tooth Number OR the appropriate code for the Quadrant Number
when required. Quadrant values are: 10-Upper right; 20-Upper left; 30-Lower left; 40-Lower right.
Enter the appropriate Surface value (I-Incisal; F-Facial; O-Occlusal; L-Lingual; B-Buccal; M-Mesial;
D-Distal).
Not Required. Use only ICD-9 codes or enter the diagnosis indicator # (1-8) from field 58. Do not
use SNODENT codes.
Enter the CDT - 2007/2008 procedure code that best describes the service.
Enter the Units of Service.
Not required
Enter the billed amount for the service provided
60
Identify all missing teeth
Total Fee
Payment by Other Plan
Maximum Allowable
Not required
Enter the sum of all detail billed amounts on the claim.
If other insurance made a payment prior to Medicaid (as indicated in Fields 31-36 above), enter
the amount of that carrier’s payment.
Not required
61
Deductible
Carrier %
Not required
Not required
Dental Billing Provider Billing Manual
Field Number
Name
Instructions for Completion
Carrier Pays
Remarks
If applicable, subtract the “payment by other plan” from the “Total Fee” and enter that difference in
this field.
Enter remarks only if program service limitations require additional explanation of the service
provided.
62
Signature
Provide original signature of the dentist or other authorized signer and the date of completion of
the claim form.
63-66
Address Where Treatment Performed
Not required