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Web billing dentist or dental entity (leave blank if dentist or dental entity is not submitting treating dentist and treatment location information claim on behalf of the patient or insured/subscriber) 53. Web leave blank when the dentist is not aware of any other coverage(s). For providers already in calvcb’s system: Web get form pdf editing your way complete or edit.
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Web double check all the fillable fields to ensure total precision. Any updates to these instructions will be posted on the ada’s web site (ada.org). The advanced tools of the editor will direct you through the editable pdf template. Press done after you fill out the blank. I hereby certify that the procedures as indicated by date are in progress.
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