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?
No
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
No
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
$
1
/
/
/
/
$
2
/
/
/
/
$
3
/
/
/
/
$
4
/
/
/
/
$
5
/
/
/
/
$
6
/
/
/
/
$
7
/
/
/
/
$
8
/
/
/
/
$
9
/
/
/
/
$
10
/
/
/
/
$
11
/
/
/
/
$
12
/
/
/
/
$
13
/
/
/
/
$
14
/
/
/
/
$
15
/
/
/
/
Note: Please refer to the DVA Fees Schedules for details of the annual monetary limits for treatment.
ORIGINAL (white copy) - Department
DUPLICATE (green copy) - Patient
TRIPLICATE (pink copy) - Dental Provider
D919 02/13