Combined Dental Agreement (CDA)
DHB-funded oral health services for adolescents (aged from school year 9 up to the 18th birthday) and special dental services for children and adolescents are provided under the nationally standardised Combined Dental Agreement (CDA).
Check your agreement for the full definitions, terms and conditions of services to be provided and claimed for payment under the CDA. The Operational Guidelines issued with each agreement include guidance on claiming.
Forms for the CDA
The current CDA took effect on 1 July 2019. 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).
Pads of printed forms are available by phoning 0800 855 066, option 6.
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.
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.)
- Enrolment for adolescent oral health services (Word, 41 KB)
- Enrolment for adolescent oral health services (PDF, 36 KB)
Send the completed enrolment form to:
Sector Operations
Private Bag 3015
Whanganui Mail Centre
Whanganui 4540
Claim forms
- Claim summary form (Word, 39 KB)
- Claim summary form (PDF, 126 KB)
- Individual treatment report (Word, 53 KB) – use for consultation only services as well as treatment services
- Individual treatment report (PDF, 142 KB) – use for consultation only services as well as treatment services
You’ll need to send in a completed claim summary form along with the individual treatment report(s).
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
- High caries treatment planning (adolescents) treatment report/claim summary form (Word, 40 KB)
- High caries treatment planning (adolescents) treatment report/claim summary form (PDF, 140 KB)
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
- High caries treatment planning – application to provide treatment (Word, 43 KB)
- High caries treatment planning – application to provide treatment (PDF, 133 KB)
Application for approval to provide treatment not covered by standard fee schedule
- Application for approval to provide treatment not covered by standard fee schedule (Word, 47 KB)
- Application for approval to provide treatment not covered by standard fee schedule (PDF, 119 KB)
Special dental services
Special dental services are for children and adolescents under the age of 18 years who are eligible for free dental care.
- Claim summary form (Word, 35 KB)
- Claim summary form (PDF, 126 KB)
- Individual treatment report (Word, 54 KB)
- Individual treatment report (PDF, 97 KB)
You’ll need to send in a completed claim summary form along with the individual treatment report(s).
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.
Emergency dental care for low income adults
- Claim for emergency dental care for low income adults (Word, 43 KB)
- Claim for emergency dental care for low income adults (PDF, 72 KB)
Submitting claim forms
Send completed claim forms to:
Sector Operations Dental Claims
PO Box 1026
Wellington 6140
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 filled out a form on your computer, print it off and send to the address above. Remember to keep a copy for your own records.
If you have any questions about the claim form requirements, call Sector Operations on 0800 855 066.
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.