Dental claim and enrolment forms
We provide 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), Health New Zealand 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.
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).
Pads of printed forms are available by phoning 0800 855 066, option 6.
Enrolment form
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
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
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 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
High caries treatment planning — application to provide treatment
Application for approval to provide treatment not covered by the standard fee schedule
Application for approval to provide treatment not covered by the standard fee schedule
Special dental services
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
The Equity Index
To see the most up-to-date information on equity index numbers for schools in your area, visit the Ministry of Education website.
The 2024/25 CDA will adopt the EQI, and will classify payments as follows:
|
New EQI Score |
Equity Index |
Code |
Price (GST excl.) 2024/25 |
|
569 to 491 |
Band 1 |
COM1 |
$239.19 |
|
490 to 448 |
Band 2 |
COM2 |
$184.27 |
|
447 to 365 |
Band 3 |
COM3 |
$150.84 |
If a patient is attending a high school that is not assigned an EQI number by the Ministry of Education, the price paid to you for the patient will be the price we pay for patients attending high schools in Band 3.
If a patient is not enrolled at a high school, the price paid to you for the patient will be the price we pay for patients attending high schools in Band 2.
Submitting claim forms
The primary method for submitting completed CDA claim forms is to email them to cdaclaims@health.govt.nz
For those unable to email, you can post completed CDA 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. You will need to provide your payee number. The forms are free.
Contact Sector Operations
If you have any questions about the claim form requirements, call Sector Operations: