Fillable Dental Report And Voucher Form 2013 (Page 2 of 4) in pdf

Dental Report And Voucher Form 2013 Page 2

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Dental Report and Voucher

Australian Government

Department of Veterans’ Affairs

The Department of Veterans' Affairs requires the information provided on this form to verify the service(s) provided

and process the claim for payment. It will be disclosed to Medicare Australia for payment purposes.

Patient details

Claimant details (continued)

DVA file number

Name

Surname

Address

Postcode

First name

Initial

Treatment Card

Telephone

(

)

Gold

Name of practitioner who provided the services (if not the claimant)

White

Condition treated

Is the practitioner a locum?

Yes

Number of kilometres travelled

Complete this section only if you do not know the patient's file number

Was emergency out-of-hours treatment provided?

Address

Yes

Please attach brief details of time, date

and nature of the emergency treatment

Postcode

Treatment location other than in rooms:

Home

Date of birth

Hospital

Telephone

(

)

Name of hospital or nursing home where

Nursing Home

treatment was provided

Replacement Dentures

Reason for replacement dentures within 6 years:

Lost

Claimant declaration

Please attach a written declaration

Broken

signed by the entitled person

Please sign when treatment is completed and/or when you are submitting this form

(unable to be repaired)

for payment.

Claimant details

I have provided the dental treatment described on the Record of Treatment on this form.

Dentist/Specialist

Dental Prosthetist

Claimant's signature

Provider number

Date

Continued next column

Record of Treatment

If you provide more than one item during the one visit, the patient must sign and date the Record of Treatment at least once, adjacent to the last item recorded for that visit.

Date

Item No.

Tooth No.

Amount claimed

Signature of patient

Date