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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         
    1. (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. BACS Payment Form – To Register a new Dental List Number
  11. BACS Payment Form – Change or Amendment Form
  12. DRPA Form – Dental Review of Practice Allowance (PDF Format)
  13. DPRA Form – Dental Review of Practice Allowance (Microsoft Word Format)

Update Notes:

  • Number 3 updated (6th February 2023)
  • Numbers 10 & 11 updated (26th July 2023)
  • Numbers 5, 6 & 9 updated (October 2023)
  • Number 4 updated (6th February 2024)

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 (10-Jan-24, Revised version from May-23)

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

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Also in this Section