Forms Library

Dental Finance Forms

1. Assistant Salary Form

2. CPDA Form for courses from 1st April 2018 onwards

3. DA1 Form - Declaration for Health Service Committed Dentists (Please click here for guidance in relation to completion of DA1 form)

4. HS50 Form - Arrangement for Transfer of Patients

5. Maternity/Paternity/Adoption Payments Claim Form

6. OP2 Form - Claim for Long-Term Sickness Payments

7. OP4 Form - Return to Work Form

8. PREM1 Form - Reimbursement of Non-Domestic Rates

9. SEN 1 Form - Application for Seniority Payments.

10.Dental BACS Payment Form 2018

 

HS48 Forms 

Please click here to view forms and associated documentation for new entrants to the NI Dental List.

 

Dental Treatment Forms

1. DB100 Form - Stationery Order Form

2. DB114(a) Form - Orthodontic Diagnosis: Non-Appliance Cases

3. DIS1 Form - Paid Claim Adjustments

4. HS45DOC Form - Dental Care Orthodontic Acceptance

5. NON2 Form - Non Payment Enquiries  

6. RA1 Form - Application for Replacement of a Dental Appliance

7. WCA966 Form - Notice of Withdrawal from a Capitation or Continuing Care Arrangement

 

 

Dental Prescription Pads / Controlled Drugs

1. Letter regarding use of Dental Prescription Pads by second parties

2. Form authorising use of Dental Prescription Pad by a second party

3. DLRS Prescription Re-Ordering Forms

4. Link to Guidelines on Private Controlled Drugs

5. Controlled Drugs Self Assessment Questionnaire Declaration - Microsoft Word format

6. Controlled Drugs Self Assessment Questionnaire Declaration - PDF format