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The ADA Dental Claim Form provides a common format for reporting dental services to a patient's dental benefit plan. A sample form for an employee to request an accommodation due to disability.A sample form for a health care provider to complete when an employee requests an ADA accommodation. Attach additional pages as needed. Employees and applicants for employment may submit written or verbal requests for accommodation and must not be required to complete this form. Gov) Please return by:. By completing this form, the County employee recognizes the need for, and. There is no need to mention the ADA or use the phrase "reasonable accommodation. Dory Funk, fill out the form. Separate, fully completed claim form.