Dental Claim Form

Dental Claim Form Template for Netherlands

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Key Requirements PROMPT example:

"I need a standard Dental Claim Form for my practice in Amsterdam that complies with 2025 Dutch healthcare regulations, includes English translations alongside Dutch text, and has built-in KNMT code validation to minimize processing errors."

Document background

The Dental Claim Form is a crucial document in the Dutch healthcare system, designed to facilitate the processing of insurance claims for dental treatments. It is used when patients seek reimbursement for dental procedures covered under their insurance policies. The form must comply with the Zorgverzekeringswet (Healthcare Insurance Act) and other relevant Dutch healthcare regulations. It includes sections for patient identification, treatment details using standardized KNMT codes, cost specifications, and necessary declarations. The document ensures proper documentation for insurance processing while maintaining compliance with AVG (GDPR) requirements for handling personal medical data. This standardized form streamlines the claim process for all parties involved: patients, dental practices, and insurance providers.

Suggested Sections

1. Patient Information: Essential personal details including name, date of birth, insurance number, contact information, and BSN (Dutch social security number)

2. Insurance Details: Information about the insurance policy, including policy number, type of coverage, and insurance company details

3. Dental Practice Information: Details of the dental practice, including AGB code, dentist's name, and practice contact information

4. Treatment Details: Specific information about the dental treatment(s) provided, including dates, treatment codes, and tooth numbers

5. Cost Specification: Detailed breakdown of treatment costs, including individual procedure costs and total amount claimed

6. Declaration and Signatures: Declarations of accuracy and consent sections, requiring signatures from both the dentist and patient

Optional Sections

1. Accident Information: Additional section required when the dental treatment is related to an accident, including date, circumstances, and other insurance details

2. Specialist Referral Details: Required when the treatment involves a referral to a dental specialist or other healthcare provider

3. Previous Treatment History: Section for relevant previous treatments that relate to the current claim

4. Third-Party Payment Authorization: Optional section for cases where payment should be made directly to the dental practice rather than the patient

5. International Treatment Details: Required for treatments received outside the Netherlands, including currency conversion and foreign provider details

Suggested Schedules

1. Treatment Codes List: Complete list of standardized Dutch dental treatment codes (KNMT codes) and their descriptions

2. Required Documentation Checklist: List of required supporting documents for different types of claims (e.g., X-rays, specialist reports)

3. Payment Terms and Conditions: Detailed information about claim processing, payment timeframes, and conditions

4. Privacy Notice: Detailed information about how personal and medical data will be processed, shared, and protected in accordance with AVG/GDPR

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Dental Care

Insurance

Healthcare Administration

Medical Services

Financial Services

Relevant Teams

Claims Processing

Healthcare Administration

Dental Operations

Insurance Operations

Compliance

Medical Records

Patient Services

Healthcare Finance

Risk Management

Customer Service

Relevant Roles

Dentist

Dental Assistant

Insurance Claims Processor

Healthcare Administrator

Insurance Coordinator

Dental Practice Manager

Healthcare Claims Specialist

Compliance Officer

Medical Records Administrator

Insurance Policy Administrator

Healthcare Finance Manager

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Authors

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