IMPORTANT
Dental Report and Voucher
Instructions for use
Prior Approval
Please obtain Prior Approval from the Department before
This form is supplied in triplicate. Please distribute the
providing the following treatment:
copies as follows:
1. all Schedule B services;
•
Original (white copy) - Department
2. each course of dental treatment for holders of a White
•
Duplicate (green copy) - Patient
Card;
•
Triplicate (pink copy) - Dental Provider
3. all services not listed in the LDO and Dental Prosthetists
Fees Schedules;
Claiming payment
4. Schedule C items included in treatment plans for ex-
POWs and entitled persons receiving dental treatment
When claiming payment, you must attach the Department's
in relation to war-caused conditions and malignant
copy of this form to a Claim for Treatment Services (Form
neoplasia, as these beneficiaries are not subject to the
D1217) and forward it to Medicare Australia for
annual monetary limit (see below);
processing.
5. all Fee by Negotiation items;
Completing the form
6. replacement of dentures within six years of issue. It
is the dental provider's responsibility to check the age
Patient details: write the patient's DVA file number and
of existing dentures. If in doubt please contact the
full name in this section. Include address, date of birth
Department before proceeding;
and phone number (shaded section) only if you do not
7. replacement of dentures within twelve months of the
know the patient's file number.
reline of existing dentures;
Claimant details: write the provider number, name,
8. reline(s) to each upper or lower denture within two
address and telephone number of the claimant in this
years of provision of new dentures or the reline of
section. If the claimant did not personally provide the
existing dentures (except for one reline within two years
services, write the name of the practitioner who provided
of the provision of immediate dentures);
the services in this section and indicate whether the
9. referral of a DVA beneficiary to an Orthodontist,
practitioner is a locum.
Prosthodontist or oral medicine specialist.
Claimant declaration: the claimant must sign and date
the claimant declaration when treatment is completed
Annual Monetary Limit
and/or when submitting the form for payment.
An annual monetary limit applies to Schedule C items of
Record of treatment: write the date of service, item
the LDO Fees Schedule. Please refer to the current LDO
number, tooth number and amount claimed in this section.
Fees Schedule for the limit for this calendar year. You can
The patient must verify that he/she has received the dental
contact DVA on 1300 550 457 or 1800 550 457 (non-
treatment listed in this section by signing and dating each
metropolitan callers) to check on a veteran’s available
item. If more than one item is provided during the one
monetary limit.
visit, the patient is required to sign and date this section
Subject to written Prior Approval, all ex-POWs and entitled
at least once, adjacent to the last item recorded for that
persons receiving dental treatment in relation to war-caused
visit.
injuries or malignant neoplasia are exempt from the limit.
Eligibility for dental treatment
Freedom of Information
•
DVA beneficiaries who are eligible for treatment of
Under the Freedom of Information Act 1982 the patient
all conditions are issued with a Repatriation Health
may obtain access to this form subject to the application of
Card - For All Conditions (GOLD CARD).
relevant exemption provisions specified in the Act.
•
DVA beneficiaries who are eligible for treatment of
only war-caused conditions and malignant neoplasia
are issued with a Repatriation Health Card - For
Specific Conditions (WHITE CARD).
D919 02/13