Physician's account (invoice) to WorkplaceNL for services on a claim.
- Completed by
- Physician
- Issued by
- WorkplaceNL
- Format
- Language
- English
WorkplaceNL Form 96: Dentist's Final Report and Account
Dentists bill WorkplaceNL on this one-page form for dental care given to an injured worker, ticking either the final report and account or the recurrence report and account. It records whether treatment is complete, a calendar of consultation and treatment dates coded by type, and itemized procedures from extractions and fillings to crowns, bridges, dentures, X-rays and anaesthetic.
Who completes it
The attending dentist completes and personally signs the whole form, with their WorkplaceNL billing number, and stamps or types their name and address. The declaration confirms the services were personally rendered and the fees are no more than would be charged if the worker were paying.
Submitting and payment
- How to submit it
- Fax only: the form says it is to be faxed, not mailed. Submit the account within thirty days of the completion of treatment.
- Who pays
- WorkplaceNL pays the dentist for the itemized services billed with the fee item codes from its Fee Guide, and a consultation fee only when WorkplaceNL authorized the consultation.
Good to know
- Quote the fee item code from the Fee Guide for each service, with the tooth number for extractions, fillings, crowns, bridges, dentures and operations.
- A consultation fee is payable only when WorkplaceNL authorized the consultation, so confirm authorization before billing it.
- Billable lines include the Examination and Report (Form 67 or equivalent), X-rays and anaesthetic, with the anaesthetic's type and duration detailed in the remarks.
- Mark each visit in the month-by-day calendar with a code: O office, H hospital, C consultation, X X-ray, A anaesthetic or Z operation.
Get the official form
Download the current version from the source each time; forms change without notice.
Invoice – Dentists (Form 96)
Fill it with Vero
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.
How this list is checked
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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Frequently asked questions
Can I mail WorkplaceNL Form 96?
No. The form is marked to be sent by fax only, and WorkplaceNL asks for dental accounts within thirty days of the completion of treatment. Before faxing, make sure the claim number, your WorkplaceNL billing number and the worker's MCP number are on the form, along with the date of injury.
What is the difference between the final and recurrence report on Form 96?
Form 96 carries two headings and you tick one: Dentist's Final Report and Account, or Dentist's Recurrence Report and Account. Either way, the form asks whether dental treatment has been completed and, if so, on what date, and lists the consultation and treatment dates and the procedures billed.
Which fee codes go on WorkplaceNL Form 96?
The fee item codes shown in WorkplaceNL's Fee Guide, which the form asks you to quote for each service, along with the schedule number, the number of services and the amount. Extractions, fillings, crowns, bridges, dentures and operations also need the tooth number.