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Get Ameritas Dental Claim Form 2016-2024

TREATMENT RECORD Tooth number, letter, DESCRIPTION OF SERVICES quadrant or arch Surfaces (including x-rays, prophylaxis, materials used, etc) CDT ADA Procedure Code Date Service Performed Month Day Year Fee 25. Remarks for unusual services 26. Total fee charged 27. CERTIFICATION: I hereby certify that the services listed above have been performed on the dates indicated and that the fees submitted are the fees I have charged and intend to collect for those purposes. 28. Address where t.

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