Fillable Dental Report And Voucher Form 2013 printable pdf download

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

Dental Report And Voucher Form 2013

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