NHS Form

Practice Record Form - Patient Declaration

Patient Information

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I consent to the Fulham Dental Centre, to examine me under the NHS and to give me any necessary care and treatment that I am willing to undergo within NHS arrangements. I agree to pay the statutory charges for the NHS dental service I receive, unless I have completed a valid claim for free or reduced cost NHS dental services below, and that I may have to pay the full amount prior to treatment. I agree, if necessary, to be examined and/or to have my dental records examined by the NHS Business Services Authority (NHSBSA) or other authorised bodies. I declare that the information I give on this form is correct and complete. I understand that if it is not, appropriate action may be taken against me.

To enable the NHS to prevent and detect fraud and mistakes, pay dentists and to secure the effective and efficient delivery of NHS and related services, relevant information on your NHS treatment may be shared with, and by the NHSBSA to NHS England, Department for Work and Pensions, HM Revenue & Customs, NHS Digital, NHS Counter Fraud Authority, NHS Service Commissioners and bodies performing functions on their behalf. Your personal data will be deleted within 10 years of receipt into our systems. Further details are available at www.nhsbsa.nhs.uk/yourinformation

Signature:

What is your ethnic group?

Please provide your preferred method of contact below, as an alternative to your postal address.
By providing this information, the NHSBSA may use this method to contact you to survey your NHS dentistry experience.

Are you claiming for free/reduced cost for NHS Dental Services?

Yes No

You Must Read This Form Before You Sign It. Only Sign It If It Is Correct.

The patient is responsible for the accuracy of this claim, NOT the dental practice.
If you’re not certain that you’re entitled to receive free or reduced cost NHS dental services you MUST pay the dental practice. If you subsequently confirm that you were entitled to free or reduced cost dental services, you can claim a refund. If you have applied for a qualifying benefit or exemption certificate but have not received it yet, you must pay and claim a refund when/if you do receive it.
Checks on claims are undertaken to confirm you are entitled. Incorrect claims for free or reduced cost NHS dental services will result in a penalty charge of up to £100, in addition to the cost of NHS dental services. You won’t have the opportunity to pay for the services first to avoid the penalty charge.

a) I am entitled to free NHS dental services because on the first day of treatment:

I am under 18 years of age

I am 18 years of age and in full time education

I am pregnant

I had a baby in the last 12 months

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I am currently in prison or a young offenders institution

b) I am entitled to free NHS dental services because during the course of treatment I get, or am included in an award (as a claimant, partner, or dependent person under 20) of:

Income Support (Incapacity benefit and Disability Living Allowance does NOT count)

Income-based Jobseeker’s Allowance (Contribution-based does NOT count)

Income-related Employment & Support Allowance (Contribution-related does NOT count)

Pension Credit Guarantee Credit (Savings Credit on its own does NOT count)

Universal Credit (in the last assessment period there were no earnings, or earnings were within the allowed limit, please check at www.nhs.uk/healthcosts)

Please complete details below

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During the course of treatment these are the only benefits that entitle you to free NHS dental services

c) I am entitled to free NHS dental services because I am named on one of the following certificates that is valid during the course of treatment:

HC2 Certificate

NHS Tax Credit Exemption Certificate/Card (or entitled to one)

(You are not automatically entitled because you receive Tax Credits; there are qualifying conditions, please check at www.nhs.uk/healthcosts. If you qualify you will be sent an exemption certificate/card, but if you don’t have one you can use the award notice as proof.)

d) I am entitled to reduced cost NHS dental services because:

I am named on a HC3 certificate that is valid during the course of treatment which limits the amount I have to pay to:

I confirm that the information I have given above is correct and complete and that I am entitled to free or reduced cost NHS dental services as above. I understand that I will have to pay for my treatment and a penalty charge of up to £100, if it is not correct and I am not entitled.

If you are signing for the patient give details below:

Signature:

fulham dental centre

NHS Form

PR (01/04/2018 R7)

Practice Record Form - Patient Declaration

Patient Information