Practice Record Form – NHS Patient Declaration- MUST BE COMPLETED
ONE FORM MUST BE COMPLETED FOR EACH COURSE OF TREATMENT This data is to be retained in the Dental Practice unless requested by the NHSBSA or other authorised body
PROVIDER INFORMATION
Provider name & address: Willerby Dental Care, 81 Kingston Road. Willerby, HU10 6AH
PATIENT INFORMATION
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 8 years of receipt into our systems. Further details are available at www.nhsbsa.nhs.uk/yourinformation
CLAIM FOR FREE OR REDUCED COST NHS DENTAL SERVICES
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.