Dental Insurance Claim Form

Filing a dental insurance claim shouldn't feel like pulling teeth. This dental insurance claim form template gives patients and dental offices a clear, organised way to submit claims for treatment reimbursement—complete with procedure codes, treatment dates, provider information and digital X-ray uploads.

Whether you're a dental practice processing claims on behalf of patients or an individual submitting for reimbursement, this template captures everything insurers need to process claims quickly: CDT procedure codes, tooth numbers, treatment costs, pre-authorization references and supporting documentation.

Built with Paperform, this template offers conditional logic to show relevant fields based on claim type, file upload capabilities for X-rays and receipts, and calculation fields that automatically total treatment costs. You can customise the form to match your practice branding, embed it on your website, or share it as a standalone link.

Connect this form to your practice management software via Stepper (stepper.io) to automatically route submitted claims to your billing team, update patient records, and trigger follow-up workflows. For practices handling high claim volumes, automation ensures nothing slips through the cracks and patients get faster reimbursement.

With SOC 2 Type II compliance and secure file handling, Paperform keeps sensitive health information protected throughout the claims process. This template is ideal for dental practices, orthodontists, oral surgeons, and patients managing their own insurance claims.