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Stationery Bill Format

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					                            DRAFT COPY amended 15 Nov 2007 09:59 by Matthew Blundy 02 9832 3289




Instruction Sheet:
Bulk Bill Stationery for
DB1N-DP—Web header
(Dental Practitioners)
IMPORTANT:
Please refer to this instruction sheet when completing direct payment vouchers as incorrect/incomplete information on
the voucher may result in errors/delays in payment of benefits.
Format:
 If you are completing the form electronically, you are only required to complete the Medicare copy—the other copy
    will pre-fill.
 If you are printing the form to complete manually, you will need to complete both copies.
 Carbon copy forms can be ordered from Leigh Mardon on 1800 067 307**.
Each field on the form is explained below:
1.    The code DB1N-DP represents the form type. DP stands for Dental Practitioner.
2.    Complete the name and address of the Dental Practitioner who rendered the service(s) being claimed.
      Complete the Dental Practitioner’s provider number.
      Note: if payment is to be made to a Dental Practitioner other than the service Dental Practitioner—complete
      the dental practitioner’s name and provider number in the relevant box on the left hand side of the form.
CLAIM DETAILS
3.    Enter the date which the practitioner is submitting the claim in DD/MM/YY format.
4.    CLAIM NUMBER—All claims submitted for payment need to have a claim number. This can be any
      combination of one alpha and four numeric digits (for example, A0001). Dental Practitioners will need to
      quote this number to Medicare if they want to enquire about the claim.
5.    Add up the number of forms (DB4-DP) that you are attaching to the header and write the total in the number
      of assignment forms boxes.
6.    Complete the total benefi t amount claimed box. This is the total of all of the assignment forms you are
      attaching to this claim.
DECLARATION
7.    The Dental Practitioner who rendered the services signs the form acknowledging the declaration.
      This signature must be witnessed and the form dated.
      Note: once the form has been signed, the Dental Practitioner must:
      send the MEDICARE COPY to the nearest Medicare Office with the assignment forms (DB4-DP).
      Medicare Australia recommends that you do not attach any more than 50 assignment forms for
      each header
       retain the PRACTITIONER COPY.
Before the patient signs the assignment form, all the details of the service(s) must be completed. Once the required
fields have been completed ask the patient to:
sign in the signature box located on the left hand side of the form
enter the current date (next to the signature mentioned above).
Where the patient is unable to sign and date the assignment form, an explanation as to why the patient was unable to
sign should be provided and initialled by the dental practitioner.
Note: once the assignment form has been signed, the Dental Practitioner must:
 pass the PATIENT COPY directly to the patient
                                                                                                                          2072.15.11.07




 send the MEDICARE COPY to the nearest Medicare Office with the assignment forms (DB4-DP) attached. Medicare
     Australia recommends that you do not attached any more than 50 assignment forms for each web header
 retain the PRACTICE COPY.                                        ** Call charges apply from mobile or pay phones only

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