Dental Claim Form

Dental Claim Form Template for New Zealand

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Key Requirements PROMPT example:

"I need a standard Dental Claim Form for a private dental insurance provider in New Zealand, with additional sections for employer-sponsored coverage and the ability to claim for multiple family members under the same policy."

Document background

The Dental Claim Form is a crucial document in New Zealand's dental healthcare system, designed to streamline the process of claiming payment or reimbursement for dental treatments. This standardized form is used when patients seek compensation from insurance providers, ACC, or employee benefit schemes for dental services received. The form captures comprehensive information including patient details, treatment specifications, cost breakdowns, and practitioner information, ensuring compliance with New Zealand's health information privacy regulations and insurance requirements. It serves multiple purposes: documenting the treatment provided, establishing the basis for payment, and creating an auditable record for all parties involved. The form is particularly important in cases involving insurance claims, accident-related dental work covered by ACC, or employee dental benefits.

Suggested Sections

1. Patient Information: Essential details including full name, date of birth, contact information, and insurance policy number

2. Treatment Details: Information about the dental treatment received, including dates, procedure codes, and tooth numbers

3. Dentist Information: Treating dentist's details including name, practice details, and registration number

4. Payment Details: Bank account information or preferred payment method for claim settlement

5. Cost Breakdown: Itemized list of treatments and their individual costs, including any GST components

6. Declaration: Patient and dentist declarations confirming the accuracy of information and consent for information sharing

Optional Sections

1. ACC Claim Details: Additional section for accident-related dental claims, including accident date and ACC claim number

2. Third Party Authorization: Section for cases where someone other than the patient is managing the claim

3. Previous Treatment History: Details of related previous treatments when relevant to the current claim

4. Alternative Insurance Coverage: Section for declaring other insurance policies that might cover the treatment

5. Employer Details: Required when claim is part of employee health benefits or workplace accident

Suggested Schedules

1. Schedule A: Fee Schedule: Standard fee schedule for common dental procedures as per current New Zealand Dental Association guidelines

2. Schedule B: Required Documentation Checklist: List of supporting documents required for different types of claims

3. Schedule C: Terms and Conditions: Detailed terms and conditions of the claim process and payment arrangements

4. Appendix 1: Dental Chart: Standard dental chart for marking treated teeth and procedures

5. Appendix 2: Treatment Codes Guide: Reference guide for standard dental procedure codes used in New Zealand

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

Insurance

Dental Services

Medical Administration

Employee Benefits

Public Health

Professional Services

Relevant Teams

Finance

Claims Processing

Patient Services

Healthcare Administration

Compliance

Benefits Administration

Customer Service

Medical Records

Account Management

Operations

Relevant Roles

Dental Practice Manager

Insurance Claims Processor

Healthcare Administrator

Benefits Coordinator

Dental Assistant

Office Manager

Claims Adjuster

Compliance Officer

Patient Services Representative

Account Manager

Medical Records Officer

Insurance Verification Specialist

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