Print ADA and Canadian Insurance Forms

You can print ADA 2006, ADA 2012, ADA 2019, and Canadian insurance forms on plain paper with an approved laser printer. Choose from a variety of formats.

Get Started

Set Up Insurance Submission Defaults - Use the Insurance Setup editor to specify whether insurance benefits are paid to the patient, as well as select your default insurance submission method, and default recurring insurance code. You can also specify a third-party billing name and address for insurance claims, and enter your Claim Connect credentials for electronic submissions in this editor. See "Set Up Insurance Submission Defaults" for details.

Select Default Insurance Form Format - Use the Default Forms section of your Reports and Forms editor to select the default format to use for your forms. This is the format that will be used when you run the form from the Forms option of the Home or Patient ribbon bar. If you have purchased customized forms, you may choose your form as the default. See "Set Up Reports and Forms" for details.

Enter Insurance Data in Patient Folders - Use the Insurance page of the patient folder to enter the information you will need for submitting insurance claims. You will need to enter insurance details for each treatment phase and insurance contract. If you use Canadian insurance forms, be sure you have assigned the correct form to your Reports and Forms editor See "Patient Insurance Details" for details.

Assign Email Merge Document - If you will be emailing this form to your patients and parents, you must use your Reports and Forms editor to assign the mail merge document to use as the text of your email message. See "Set Up Reports and Forms" for details.

Run This Form

1. Open the Form - You can open this feature in multiple ways: Use the method that's most convenient for you. Be aware that if you open insurance forms from the Patient or Home ribbon bar Forms icon, the insurance form format that will be generated (i.e. ADA 2019 or Canadian Insurance Form) is set up in the Reports and Forms editor, and cannot be changed here. See "Set Up Reports and Forms" for details.)

   Patient Ribbon Bar - Patient section > Forms > Insurance. (An Edge Cloud patient folder must be open for the Patient ribbon bar to be available.) If the patient has multiple contracts, you will need to select the contract to print for. Be sure to look at the treatment phase, insurance company, and billing party when making your selection. The first time you initiate this form, you will set your Quick Report settings for a patient insurance form. From then on, the form is loaded with those settings automatically. In addition, the insurance form format that will be generated (i.e. ADA 2019 or Canadian Insurance Form) is set up in the Reports & Forms editor, and cannot be changed here. See "Set Up Reports and Forms" for details.

   

   Home Ribbon Bar - Tasks section > Forms > Scheduled Insurance. The first time you initiate this form, you will set your Quick Report settings for scheduled insurance forms. From then on, the form is loaded with those settings automatically. In addition, the insurance form format that will be generated (i.e. ADA 2019 or Canadian Insurance Form) is set up in the Reports & Forms editor, and cannot be changed here. See "Set Up Reports and Forms" for details.

   

   Home Ribbon Bar - Reporting section > Reporting > Form > ADA 2006, ADA 2019 or Canadian Insurance Form > Select an insurance form > Run. (You can also use the Search field to find the form you want to work with.) You might also be able to run this form from your Recent Reports or Quick Reports list. See "Run Reports" for details.

   

2. Specify Paper Forms - (From Home or Patient ribbon bar > Forms option only.) When you initiate an insurance form from the Forms option on the Home or Patient ribbon bar, you may be asked whether you want to generate paper or electronic claims. Select the Paper option to continue with the instructions below.If you always print paper insurance forms, you can set up Edge Cloud to bypass this prompt. See "Set Up Insurance Submission Defaults" for details.

   

3. Form Settings - (You choose and save default form settings the first time you initiate an insurance form from the Forms option of the Home or Patient ribbon bar, but you can change them for an individual printing job as needed. ) Select the options to use for generating this form. Note that not all options are necessary for all insurance forms: Only those required by the form you have selected will be available to you. A number preceding an option indicates the insurance form field that will be filled in with that information. (If the settings panel is not visible, click the  Show/Hide icon in the upper left corner of the Reporting window.)

   Form Date - Enter the date you want printed as the form generation date, generally today. You can also enable the Today option to automatically run the forms for today's date.

   Report Type - Choose the type of insurance form to generate.

   Statement of Actual Services - The Statement of Actual Services insurance form bills for the entire contract, as shown on the Insurance page of the patient folder, or for any Additional Services Provided records that you have added to the detail page. You can print this form on plain white paper, or submit the claim electronically. (See "Patient Insurance Details" for details. about Additional Services Provided records.)

   Pre-Treatment Statement / Pre-Authorization - You submit this form prior to services to obtain pre-authorization.(The Canadian insurance form offers both the Pre-Treatment Statement and the Pre-Authorization insurance form, which provide for additional data entry options.

   Partial Form - The Partial Form option is a minimally-completed insurance form used for special purposes. It is filled out with the patient, subscriber, and doctor information but does not contain any actual claim, so that you can fill in the rest of the information if a special need arises.

   Scheduled Forms - This format generates this month’s scheduled continuation of treatment forms, as determined by your patient folder Insurance page settings. You can print the forms on plain white paper, or submit the claims electronically. (Note the difference between the All Scheduled insurance forms option and the Scheduled insurance forms option: The All Scheduled option prints the entire series of continuation of treatment forms for the patient(s) you select, while the Scheduled option prints the continuation of treatment forms for each patient due to receive one this month.) You can choose to print the full format form, which includes the treatment findings and financial details from the patient's Insurance page, or the single-line form, which includes only the treatment code description and fee on a single line,

   The insurance code included on this form can be different from the insurance code that appears on all other insurance forms for a patient. See "Patient Insurance Details" for details about the Insurance Code and Recurring Code fields.

   Run a Scheduled Insurance report to obtain a list of the patients for whom insurance forms are due to be generated. See "Scheduled Insurance Reports" for details.

   Miscellaneous Charge Form - The Misc.Charges option generates an insurance form for any range of dates to bill for charges you have posted in addition to the contract fees, such as diagnostic records charges. You can print the form on plain white paper or submit the claim electronically.

   Initial Claim Forms - You usually print Initial Claim insurance forms for individual patients just starting a new phase of treatment. The forms print on plain white paper with an approved laser printer. You cannot submit the form electronically.These insurance forms generate a claim for just the initial fee, not the whole treatment fee.

   Custom Fee - Single Line - The Custom Fee - Single Line forms provide a way for you to enter a custom date, insurance code and fee without entering this data into a patient folder. The data you enter into this form is not saved anywhere in Edge Cloud, but is recorded in the patient's Correspondence History.

   All Scheduled - The All Scheduled Insurance Forms option prints all the scheduled forms for the selected patient(s), not just the ones scheduled for this month. Consider using this to print all forms for a specific patient to submit him/herself if you do not accept assignment of benefits. You cannot submit this type of form electronically. (Note the difference between the All Scheduled insurance forms option and the Scheduled insurance forms option: The All Scheduled option prints the entire series of continuation of treatment forms for the patient(s) you select, while the Scheduled option prints the continuation of treatment forms for each patient due to receive one this month.)

   The insurance code included on this form can be different from the insurance code that appears on all other insurance forms for a patient. See "Patient Insurance Details" for details about the Insurance Code and Recurring Code fields.

   Dental Procedures - The Dental Procedures insurance form prints claims for dental procedures that were completed during any range of dates.

   Signature on File - (NOT available on Canadian forms) Check these items to control whether the phrase “Signature on File” appears on the Patient line, the Insured line, and/or the Doctor line of the form.

   Services Provided Order - (ADA Statement of Actual Services, ADA Pretreatment Statement only.) Choose whether to list the services provided in service-date order, or the order they were entered into the patient's insurance detail page.

   Include Current Month - (Scheduled forms only.) Enable this option to include fees for the period prior to and including the current month of treatment. Otherwise, the forms will include fees for the period prior to but not including the current month. Once you begin submitting claims, it is best not to change this setting.

   24. Show Procedure Date (ADA Initial / Scheduled forms only.) - Enable this option to include the Form Date you just entered as the procedure date on the insurance form.

   Misc. Charges to Include (Misc. Charge forms only.) - Select whether the insurance form should include All Charges (miscellaneous charges posted to the responsible party and all associated insurance detail accounts), Charges to Patient and Current Insurance (charges posted to the responsible party and the selected insurance detail), or Charges to Current Insurance (excluding charges posted to the responsible party and any other insurance detail).

   Misc. Charge First & Last Sates - (Misc. Charge forms only.) Miscellaneous charges posted between and including the first and last dates will be included. If a miscellaneous charge was not posted within the date range, it will not be included.

   Exclude Charges With No Insurance Code (Misc. Charge forms only.) - Enable this option to exclude miscellaneous charges that do not have an associated insurance code. See "Set Up Miscellaneous Charges & Groups" for details about assigning insurance codes to charges.

   48. Billing Entity Name - (NOT available on Canadian forms) Choose whether the billing name to include on this insurance claim should be your general practice name (from your Practice editor), the name of the orthodontist assigned to the patient folder, the name of the office assigned to the patient folder, or the 3rd party billing name from your Insurance Setup editor.

   48. Billing Entity Address - Choose whether the billing address to include on this insurance claim should be your general practice address (from your Practice editor), the address of the office assigned to the patient folder, or the 3rd party billing address from your Insurance Setup editor.

   49. & 54. NPI Numbers to Use - Select the NPI number to use for the Billing Entity (line 49 of the insurance form) and Treating Location (line 54). Choose from Doctor - Type 1, (from your Orthodontist editor), Assistant - Type 1/ Universities (from your Assistant Table), or Office - Type 2 (from your Office editor).

   50. Use Office License / Social / TIN for Billing Entity (NOT available on Canadian forms) - Enable this option to include the license / social / TIN number of the office assigned to the patient folder in the billing section of the form. Otherwise, the identification numbers for the orthodontist assigned to the patient folder will be used.

   55.Use Office License for Treating Entity - Enable this option to use the office license number in Treating Entity field #55 of the insurance form.

   56.Use Patient Office Address for Treating Location - Enable this option to use the patient's assigned office as the treating location. Otherwise, your general practice address is used.

   Dentist Use Only - (Canadian forms only) The text you enter in this field appears in the Dentist’s Use Only box on Canadian insurance forms. If you enable the Use Dentist Only from Patient Record option, the form will insert the text you have already entered into the Insurance tab of a patient folder, instead of the text you type here.

   Subscriber Signature - (Canadian forms only) Enter the subscriber's name here if they have agreed to assign benefit payments from this insurance company directly to your office.

   Include Patient Info - (Canadian pre-authorization form only) Enable this option to fill in the Patient Identification section of the form.

   Treatment Type - (Canadian pre-authorization form only) Select whether the Full Treatment Case; Limited Treatment Caseor Early Treatment Case box will be checked on the form, or choose not to check a treatment box.

   Brief Description of Condition - (Canadian pre-authorization form only) Type a unique description of treatment, or enable the Use Imported Findings option to instead use the findings text from the patient folder Insurance page.

   Comments - (Canadian pre-authorization form only) Type any additional information to appear in the Additional Explanatory Comments section, near the bottom of the form.

   Number of Months Valid - (Canadian pre-authorization form only) Enter the number of months this pre-authorization insurance form is valid.

4. Subgrouping - (From Home ribbon bar or Reporting tab only.) Select the subgroup to use for choosing patients that should get an insurance form. Only records that fit your selected subgroup will be included. In addition, if you have selected to generate Scheduled Insuranceforms, only patients that fit your subgroup AND are due for a scheduled insurance form will be included. (See "Patient Insurance Details" for details about scheduling insurance forms.)

   When you initiate an insurance form from the Patient ribbon bar, the form will print for that patient only; If you attempt to apply a subgroup, and the active patient does not fit the subgroup, no form will be generated.

5. View Results - If needed, click View at the top of the report settings panel to view the results on your screen. When you run a report or form from your Recent Report list, or when you run a Quick Report, the initial results are sent to your screen immediately, with one exception: A Quick Report that has the Print Only option enabled will not show your results on the screen at all, but continue with the printing options.

6. Manage Options and Output - With the results on your screen, you can choose different report settings from the left side of the screen and click View again to obtain different results. In addition, you can manage the output with the toolbar at the top of the report window. See "Use Report Results" for details.

More Information

Form Saved in Correspondence History - After you print or export a paper insurance form, or successfully submit an electronic insurance form, it is recorded in the patient’s correspondence history. See "Patient Correspondence History" for details.