Download Request for More Information on Dental Claim This form should be

Request for More Information
on Dental Claim
ACC
2303
This form should be completed to provide ACC with additional information
on a dental claim.
CLAIMANT DETAILS
ACC claim number:
Date of injury:
Claimant’s surname:
Claimant’s first name:
Date of birth:
Address:
ENTER TOOTH NUMBER, MARK RELEVANT DIAGNOSIS (MULTIPLE IF APPLICABLE) & PRE-ACCIDENT CONDITION
Periodontal disease with bone loss
Previously crowned or bridged
Medium-large filling or root canal
Extensive caries in damaged tooth
Prior damage due to ACC injury
No prior damage
Avulsion
Intrusive Luxation
Pre-Accident Condition
Extrusive Luxation
Lateral Luxation
Subluxation
Concussion
Root Fracture
Crown Root Fracture
Complicated Crown Fracture
Enamel-dentine Fracture
Enamel Fracture
Enamel Infraction
Tooth Number (one per line)
Teeth Injury Classification (Use 191Z.)
Prior damage other causes
INJURY INFORMATION
Additional Injury Comment
Soft Tissue
Gingiva
How:
laceration
abrasion
contusion
Position in mouth:
Mucosa
How:
laceration
abrasion
contusion
Position in mouth:
Lip
How:
laceration
abrasion
contusion
Position in mouth:
(Use S837.)
lower labial sulcus
Alveolar socket #
(Use S02.)
Alveolar process #
Teeth involved:
Maxilla #
(Use S02.)
Mandible #
Type / position:
Left side TMJ injury
(Use J046.)
Right side TMJ injury
Degloving injury
upper labial sulcus
Jaw / Alveolus / TMJ
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Prosthesis damaged?
(Use SP047.)
Was the prosthesis being worn at time of injury?
Yes
No
Type (describe):
If partial denture, list teeth damaged:
Other information related to dental injury claim
Permanent teeth missing prior to accident?
Yes
No
Please list:
Assessment of oral hygiene:
good
fair
poor
Assessment of periodontal condition:
good
fair
poor
Assessment of caries activity in mouth:
little or none
moderate
extensive
> Refer to:
ACC42 Form Completion Guide
DECLARATION
This information provided is for a claim which has cover.
YES
NOT SURE
NO
BUSINESS OR VENDOR NAME AND ADDRESS ( Write or Stamp)
The information on this form is true and correct and I am aware that if I give false or
misleading information about the claim, I may be prosecuted.
Signature:
Date:
ACC Provider
number:
The information collected on this form will only be used to fulfil the requirements of the Accident Compensation Act 2001. In the collection,
use and storage of information, ACC will at all times comply with the obligations of the Privacy Act 1993 and the Health Information Privacy
Code 1994.
ACC2303
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