Forms Library

Dental Finance Forms

1. Assistant Salary Form

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

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

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

5. HS50 Form - Arrangement for Transfer of Patients

6. Maternity/Paternity/Adoption Payments Claim Form

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

8. OP4 Form - Return to Work Form

9. PREM1 Form - Reimbursement of Non-Domestic Rates

10. SEN 1 Form - Application for Seniority Payments

11. BACS Payment Form - To Register a new Dental List Number

12. BACS Payment Form - Change or Amendment Form

Note: 3 & 4 updated (6th February 2023) - 10 updated (10th February 2023)

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 (PDF Format)

8. WCA966 Form - Notice of Withdrawal from a Capitation or Continuing Care Arrangement (Microsoft Word Format)

Note: 7 & 8 updated (25th January 2023)