Dentists use this one-page claim to bill WCB Nova Scotia for treating teeth damaged in a workplace injury, listing each procedure with its code, tooth, surfaces, fee and laboratory charges. A tooth chart shows teeth lost, broken or damaged, and the dentist describes each injured tooth's condition before and after the accident. WCB reimburses at the Nova Scotia Dental Association's suggested fee guide rates.
The dental surgeon completes and signs the claim, the patient signs it too, and the form ends with a WCB authorization signature. The procedure table also has columns for the WCB fee code and whether each line is approved.
Download the current version from the source each time; forms change without notice.
Dental Claim Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Circle any natural teeth completely lost because of the injury, use a straight line to show the broken part of a natural tooth, and mark artificial or crowned teeth damaged by the injury with an x. If plate or bridge work was damaged, specify it, and describe each injured tooth's condition before and after the accident.
Only with prior authorization. The form's instructions say WCB is not responsible for replacing dentures or bridges damaged by the injury, fixed or otherwise, without prior authorization from WCB. The claim also asks whether the injured teeth were natural or artificial and, if artificial, whether they were removable or permanently fixed.
WCB reimburses the dental surgeon at the rate indicated by the Nova Scotia Dental Association in its suggested fee guides for dental services, general practice or specialty as applicable. Each line on the claim lists the dentist's fee, estimated and actual laboratory charges, and the fee for work completed at the time of billing.