Dental claim and enrolment forms

Combined Dental Agreement (CDA)

DHB-funded oral health services for adolescents (aged from school year 9 up to the 18th birthday) and special dental services for children and adolescents are provided under the nationally standardised Combined Dental Agreement (CDA).

Check your agreement for the full definitions, terms and conditions of services to be provided and claimed for payment under the CDA. The Operational Guidelines issued with each agreement include guidance on claiming.

Forms for the CDA

The current CDA took effect on 1 July 2017. You can download claim forms that include all the current codes below. You can also download application forms for treatment requiring prior approval by the Approving Dental Officer (ADO).

Pads of printed forms are available by phoning 0800 353 2425, option 2.

Adolescent oral health services

Adolescent oral health services are for patients from school year 9 up to the 18th birthday who are entitled to free dental care.

Enrolment form

An enrolment form must be completed at the patient’s first visit – this must be filled out by both the patient and the dental provider. (The enrolment form is unchanged from previous years.)

Send the completed enrolment form to:

Sector Operations
Private Bag 3015
Whanganui Mail Centre
Whanganui 4540

Claim forms

You’ll need to send in a completed claim summary form along with the treatment report.

Discontinuation of annual consultation only treatment form

The annual consultation only treatment report form (HP5954) has been discontinued. Do not use this form for any services provided after 30 June 2016. Instead, use the individual treatment report form (HP5953) for consultation only services as well as for treatment services.

High caries treatment planning claim form

This form was previously called the oral health services in exceptional circumstances (adolescents) treatment report/claim summary form.

High caries treatment planning – application to provide treatment

Application for approval to provide treatment not covered by standard fee schedule

Special dental services

Special dental services are for children and adolescents under the age of 18 years who are eligible for free dental care.

You’ll need to send in a completed claim summary form along with the individual treatment report.

Decile scores

To see the most up to date information on decile scores for a school in your area, visit the Ministry of Education website.

If the patient is being home schooled, is at correspondence school, at polytech, is unemployed or is working, use the middle range (decile 4–6) rates.

Emergency dental care for low income adults

Submitting claim forms

Send completed claim forms to:

Sector Operations Dental Claims
PO Box 1026
Wellington 6140

If you are unable to download forms from the website and you need more forms, call Sector Operations on 0800 353 2425, option 2 – you will need to provide your payee number. The forms are free.

If you have filled out a form on your computer, print it off and send to the address above. Remember to keep a copy for your own records.

If you have any questions about the claim form requirements, call Sector Operations on 0800 458 448.

Returned claim forms

If your claim form is sent back, we will include a letter explaining why the form was rejected. In most cases the errors are also highlighted on the claim form.

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