Dental claim and enrolment forms
Te Whatu Ora provides funding for some child and adolescent oral and dental health services.
Pātiki and Waharua Kōpito patterns
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Combined Dental Agreement (CDA)
Under the nationally-standardised Combined Dental Agreement (CDA), Te Whatu Ora provides funded oral health services for adolescents (aged from school year 9 up to the 18th birthday) and special dental services for children and adolescents.
The current CDA took effect on 1 July 2019.
Adolescent oral health services
Adolescent oral health services are for patients from school year 9 up to the 18th birthday who are eligible for free dental care.
Forms for the CDA
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).
Approving Dental Officers’ contacts
Pads of printed forms are available by phoning 0800 855 066, option 6.
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.
Claim forms
Send in a completed claim summary form along with the individual treatment report(s).
Use the individual treatment report for consultation only services as well as treatment services
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 the 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.
Send in a completed claim summary form along with the individual treatment report(s).
Emergency dental care for low income adults
Decile scores and school numbers
To see the most up-to-date information on decile scores and school numbers for schools 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.
Submitting claim forms
Download, fill in, print and send completed claim forms to:
Sector Operations Dental Claims
PO Box 1026
Wellington 6140
Oral Health Services for Adolescents (OHSA) CDA claim forms can be emailed to cdaclaims@health.govt.nz.
If you are unable to download forms from the website and you need more forms, call Sector Operations on 0800 855 066, option 2. You will need to provide your payee number. The forms are free.
If you have any questions about the claim form requirements, call Sector Operations:
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.
Contact Sector Operations
If you have any questions about the claim form requirements, call Sector Operations: