Dental Forms

The forms center contains tools that may be necessary for filing certain claims, appealing claims, and changing information about your office.
Document Title Document Type Document Size Last Updated
ABN (AZ only) PDF 104kB 06/25/2012
Additional Location Form PDF 120kB 10/28/2024
Adult Dental Chart PDF 103kB 06/25/2012
California – Request-Refuse Interpretation Services – English PDF 405 KB 09/13/2013
California – Request-Refuse Interpretation Services – Spanish PDF 24 KB 09/13/2013
California – Request-Refuse Interpretation Services – Chinese PDF 97 KB 09/13/2013
Cavities Risk Assessment PDF 184kB 06/03/2012
Comprehensive Treatment Plan PDF 38kB 04/09/2013
Dental Claim Form PDF 727KB 12/30/2013
Dental Claim Form - Spanish PDF 1.37mB 06/04/2014
Dentist Change Form PDF 519kB 02/28/2019
DHMO Orthodontic Referral PDF 115kb 04/09/2013
DHMO Uniform Referral Form - Maryland dentists only PDF 59kB 06/03/2012
Dispute Resolution for Dentists - CA Only PDF 35KB 06/25/2012
Dissatisfaction Form (CA only) PDF 337kB 03/28/2013
NEMB (AZ only) PDF 65kB 06/25/2012
Onsite Evaluation Form PDF 606kB 08/01/2013
Oral Health Integration Program Registration Form PDF 341kB 04/16/2014
Oral Health Integration Program Registration Form Spanish PDF 344kB 04/16/2014
Pediatric Dental Chart PDF 112kB 07/03/2012
Periodontal Evaluation Chart PDF 82kB 06/25/2012
Periodic Quality Assessment (PQA) Patient Record Form PDF 134kB 03/21/2016
Periodontal Disease Risk Assessment/Eng PDF 704kB 08/01/2013
Periodontal Disease Risk Assesssment/Span PDF 717kB 08/01/2013
Periodic Quality Assessment (PQA) Facility Review Form PDF 99kB 03/21/2016
Request-Refuse Interpretation Services – English (all states except CA) PDF 106KB 03/17/2023
Request-Refuse Interpretation Services – English (all states except CA) – Readable PDF PDF 172KB 03/17/2023
Request-Refuse Interpretation Services – Spanish (all states except CA) PDF 215KB 03/17/2023
Sample PPO Orthodontial Claim Form PDF 517KB 03/28/2013
W-9 PDF 110kB 12/02/2014