NHS Patient Declaration

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.





Patient’s NHS Number

Patient’s SURNAME

Patient’s FORENAME

Patient’s Date of Birth

Is the patient exempt from paying NHS charges? Check exemption @ www.nhsbsa.nhs.uk/check

Date of appointment

I consent to the dental provider named above, or their representative, 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.

Signature/Name if over 16 years old

Date

If you are signing for the patient give details below:

Name

Relationship to patient

What is your ethnic group? Please choose ONE selection from this list to indicate your ethnic group:

Please provide your email address and/or mobile phone number:

Mobile phone number

Email address

Please note, your email address and/or mobile number held by this dental practice will be submitted to the NHSBSA for this course of treatment. Please be assured the NHSBSA will only use this information to survey you about the NHS Dental treatment you have received. If you do not want to share your email address and/or mobile number with the NHSBSA please indicate here:

Do you want to share your email address with the NHSBSA?

Do you want to share your mobile phone number with the NHSBSA?