- _ADA Forms-1
- _Scheduler-1
- 1 - Ins Type
- 1 - Patients Name [last, first, mi]
- 1- Type of Transaction
- 10 - Other Attachments
- 10a through c - Is Patient's Condition Related to:
- 10d - Reserved for Local Use
- 11 - Accident/Injury?
- 11 - Employment Related?
- 11 - Insured's Policy Group or FECA Number
- 11a - Insured's Date of Birth
- 11b - Employer's Date of Birth
- 11c - Insurance Plan Name or Program Name
- 11d - Is there another Health Benefit Plan?
- 12 - Eligibility Pending? TAR ONLY
- 12 - Release of Medical Information Signature
- 12 through 17 - Primary Subscriber Information
- 13 - Other Dental Coverage?
- 13 - Payment Authorization Signature
- 14 - Date of Current: Illness, Injury or Pregnancy
- 14 - Medicare Dental Coverage?
- 15 - If Patient has had same or similar illness
- 15 - Retroactive Eligibility?
- 16 - CHDP
- 16 - Dates Patient unable to work in current occupation
- 17 - CCS
- 17 and 17a- Name of Referring Physician or Other Source
- 18 - Hospitalization Dates Related to Current Services
- 18 - Maxillofacial - Orthodontic
- 18 through 23 - Patient Information
- 19 - Billing Provider Name
- 19 - Reserved for Local Use
- 1a - Insureds ID Number
- 2 - Patient's Name
- 2 - Patients Social Security #
- 2 - Predetermination/Preauthorization Number
- 20 - Billing Provider Number
- 20 - Outside Lab?
- 21 - Billing Provider Address/Phone
- 21 - Diagnosis or nature of illness
- 22 - Place of Service
- 22. Medicaid Resubmission Number
- 23 - Prior Authorization Number
- 23 - Proof of Elgibility
- 24 - Examination and Treatment
- 24 through 31 - Record of Services Provided
- 24a - Date(s) of Service
- 24b - Place of Service
- 24c - Type of Service
- 24d - Procedures, Services or Supplies
- 24e - Diagnosis Code
- 24f - Charges
- 24g - Days or Units
- 24h through k - EPSDT Family Plan, EMG, COB and Reserved for Local Use
- 25 - Federal Tax ID Number
- 25 - Tooth Identification Chart
- 26 - Patient's Account Number
- 26 - Tooth # or Letter; Arch; Quadrant
- 27 - Accept Assignment
- 27 - Tooth Surfaces
- 28 - Description of Service
- 28 - Total Charges
- 29 - Amount Paid
- 29 - Date Service Performed
- 3 - Name, Address, City, State, Zip Code
- 3 - Patient's Birth Date
- 3 - Patients Sex
- 30 - Balance Due
- 30 - Quantity
- 31 - Procedure Numbers
- 31 - Signature of Physician or Supplier
- 32 - Fee
- 32 - Name and Address of Facility Where Services were Rendered
- 32 - Other Fees
- 33 - Physician's, Supplier's Billing Name, Address, PIN# and GRP#
- 33 - Total Fees
- 33 - Treating Medi-CAL Provider #
- 34 - Comments
- 34 - Missing Teeth Information
- 35 - Remarks
- 35 - Total Fee Charged
- 36 - Patient Consent
- 36 - Patient Share of Cost Amount
- 37 - Insured's Signature
- 37 - Other Coverage Amount
- 38 - Date Billed
- 38 - Place of Treatment
- 39 - Number of Enclosures (00 to 99)
- 39 - Signature Block
- 4 - Insured's Name
- 4 - Other Dental or Medical Coverage?
- 4 - Patients Birth Date
- 40 - Is Treatment for Orthodontics?
- 41 - Date Appliance Placed
- 42 - Months of Treatment Remaining
- 43 and 44 - Replacement of Prothesis? Date of Prior Placement
- 45 through 47 - Treatment Resulting from
- 48 through 52 - Billing Dentist or Dental Entity
- 5 - Patient MediCAL ID#
- 5 - Patient's Address
- 5 through 11 - Other Coverage Information
- 53 - Certification
- 54 and 55 - Provider ID# and License Number
- 54 and 55 - Provider NPI and License Number
- 56 and 57- Address, City State, Zip Code and Phone Number
- 56, 56a and 57- Address, City State, Zip Code and Phone Number
- 58 - Additional Provider ID
- 58 - Treating Provider Specialty
- 6 - Patients Address
- 6 - Patient's Relationship to Insured
- 7 - Insured's Address
- 7 - Patient Dental Record#
- 8 - Patient Status
- 8 - Referring Provider#
- 9 - Other Insured's Name
- 9 - Radiographs Attached?
- 9a - Other Insured's Policy or Group Number
- 9b - Other Insured's Date of Birth
- 9c - Employer's Name or School Name
- 9d - Insurance Plan Name or Program Name
- A Word About HELP
- Account Balance
- Actions
- Actions for Appointment
- Actions for Highlighted Patient
- ADA 2002/2004 Form
- ADA 2006 Form
- Add [Charges] from CDT Group
- Add [Charges] from Treatment Plan
- Adding an Appointment
- Adding Treatment Plan Charges to Visit
- Administration
- Administrative Reports
- Aging Report
- Appointment All Resources
- Appointment Cards
- Appointment Color Blocks
- Appointment Color Legend
- Appointment Confirmation Module
- Appointment Confirmation Report
- Appointment Daysheet
- Appointment Descriptions
- Appointments
- Batch Print Encounter Forms
- Billing
- Billing Parties
- Buttons
- CDT Code Frequency - Detail
- CDT Codes
- CDT Codes with Prices
- CDT Frequency Report - Summary
- Charge Reports
- Charges Notes
- Charges/Payments by Month
- Chart Notes
- Charts and Graphs
- Click Post New Check to add a check.
- Clocking in and out
- Company Info
- Confirming Appointments
- Continuation of Treatment
- Creating a Chart
- Creating a Treatment Plan
- Creating New Buttons
- Daily Charge and Payment Summary
- Daysheet
- Defaults
- Demographics
- DentiCAL Form
- Deposit Slip
- Diagnosis Codes
- Diagnosis Frequency Report
- Documents
- EasyView
- Editing Buttons
- Electronic Claims
- Encounter Form
- Entering Charges
- Entering Patients
- Entering Visits
- Export to Telephony System
- Fee Schedules
- Financial Charts
- Financial Reports
- General
- General Patient Information
- General Settings
- Get Previous Credit
- Glossary of Terms
- HCFA Items
- HCFA-1500 aka. CMS-1500
- Header information
- Help
- Hygienist Charges Report
- Hygienist Income Report
- Income Reports
- Initial Setup
- Installation Instructions
- Instructions/Field Guides
- Insurance Companies
- Insurance Forms
- Insurance Information
- Insurance Payments
- Interfacing
- Introducing PerfectByte®
- Jump to PerfectByte
- Launch Charting
- Launch External Imaging
- Launch Perio
- Ledger
- List Style
- Lists
- Main Screen Overview
- Maintain Employee Information
- Master List Reports
- Master Lists
- Messages
- Misc.
- My Settings
- New Patient Mailing Labels - Laser
- Notes
- Overview
- Overview - Patient Information
- Overview - Posting Payments
- Overview - Visit Information
- Patient Defaults
- Patient Employer/School
- Patient Info
- Patient List Report
- Patient Listing By… Reports
- Patient Notes:
- Patient Payments
- Patient Phone Book
- Patient Recalls
- Patient Reports
- Patient Status Report
- Patient Task Pane
- Patients
- Patients by Referring Doctor
- Patient's in Pre-treatment Estimate Phase
- Payment Plan
- Payments Due from Payment Plan
- PerfectByte Timeclock
- Photos
- Photos and Docs
- Pictures
- Places of Treatment
- Post Large Insurance Checks
- Posting Payments
- Posting Payments to a Payment Plan