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Dental Narrative Submission Form Template

Create effective dental narratives for insurance claims

Struggling to compile detailed narratives for dental claims? This Dental Narrative Submission Form Template is designed for dentists like you, simplifying the process of gathering essential patient information about oral health. By using this template, you can ensure better accuracy for insurance claims, streamline submission processes, and improve patient communication, all while complying with industry standards. You'll find it easy to adapt for different treatments, such as crowns and bridges, making it versatile for all your dental narrative needs. Explore the live template and experience seamless submissions.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Patient email
Patient phone
Payer or insurance name
Subscriber ID or member ID
Pre-authorization or reference number (if any)
Relationship to subscriber
Self
Spouse
Child
Prefer not to say
Other
Please Specify:
Treating dentist full name
NPI or license number
Practice or clinic name
Practice phone
Date of service
Tooth number(s) and surfaces
Procedure code(s) (CDT)
Diagnosis code(s) (ICD-10)
Is this related to an accident or trauma?
Yes
No
Chief complaint in patient words
History of present condition (onset, duration, progression)
Clinical examination findings
Radiographic or imaging findings
Treatment performed or proposed
Medical history considerations and contraindications
Rationale for medical necessity
Summary of prior treatment and dates (if applicable)
Has this tooth or area received prior treatment?
Yes
No
Date of imaging or records
Attachments included (check all that apply)
Radiographs
Intraoral photographs
Periodontal charting
Narrative letter
Treatment plan
EOB or denial letter
Not applicable
Other
Please Specify:
Anesthesia or sedation used
None
Local anesthesia
Nitrous oxide
Oral sedation
IV sedation
General anesthesia
Not applicable
Other
Please Specify:
Were there any intraoperative or postoperative complications?
Yes
No
Complication details (if applicable)
Prognosis for the treated tooth or area
Poor
Below average
Average
Good
Exceptional
Total fee amount for this service
I certify that the information provided is accurate and complete to the best of my knowledge.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Name of person completing this form
Typed signature of provider or authorized representative
Date signed
Best email for follow-up questions
Role
Treating dentist
Billing specialist
Office manager
Dental hygienist
Dental assistant
Patient or parent/guardian
Other
Please Specify:
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Patient email","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration showcasing a dental narrative submission form template for FormCreatorAI article

When to use this form

Use this form when you need to justify treatment to a payer and prevent avoidable denials. It is ideal for SRP with 5+ mm pockets and bleeding, crown replacement due to recurrent decay under a 10-year-old restoration, or a fractured tooth that is non-restorable. Billers, office managers, and clinicians can capture diagnosis, evidence, and why the service is necessary now. Pull objective findings from the Dental exam form and align recommendations with the Dental treatment plan form. For complex cases, include perio charting, caries depth, radiographic type (BW/FM/PA), and prior treatment dates. The result is a complete, consistent narrative that helps reviewers make a fast, fair decision.

Must Ask Dental Narrative Submission Questions

  1. What diagnosis and clinical findings support the requested procedure?

    This establishes medical necessity and shows why the treatment is needed now. Include symptoms, measurements (probing depths, mobility), radiographic findings, and risk factors.

  2. Which tooth numbers, surfaces, and CDT codes are you claiming?

    Precise identifiers reduce back-and-forth and tie the narrative to billed services. List tooth numbers, surfaces or quadrants, CDT codes, and the date of service.

  3. What prior treatments, dates, and outcomes relate to this tooth or area?

    History shows progression or failure and supports replacement or retreatment. Summarize or attach details captured in the Dental history form to prove necessity.

  4. What objective evidence are you including, and when was it captured?

    Attach radiographs, perio charting, and intraoral photos, and note capture dates to strengthen your case. Clear links between images and exam notes help reviewers validate your findings.

  5. Do you have authorization to share patient records for this claim?

    Payers may require documented consent before reviewing PHI. Attach the Authorization to release dental information form and, if needed, collect a privacy acknowledgment with the Dental HIPAA form.

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