PR (01/04/2018 R7)

One form must be completed for each course of treatment.

This form is to be retained in the Dental Practice unless requested by the NHSBSA or other authorised body.

377 North End Rd, Fulham, London SW6 1NP

Tel: 020 7385 6532

Practice Record Form - Patient Declaration

Patient Information

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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:
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What is your ethnic group?
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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.
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Are you claiming for free/reduced cost for NHS Dental Services?

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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:
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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:
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:
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(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:
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If you are signing for the patient give details below:
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Signature:
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