Application for registration for a dentist who provides both NHS and Private treatments

October 2013

Applications under section 12 of are Standards Act 2000

This form must only be used by:

!ndividuals appl"ing to register as a dentist providing NHS and private treatment

It must not be used by: Dentists who provide private only treatment.

#h" do ! need to complete this form$ Under the Care Standards Act 2 and the !rivate Dentistry "#ales$ %e&ulations 2 '( dentists underta)in& any private or non*+,S funded wor) in #ales are re-uired to re&ister with ,ealthcare Inspectorate #ales ",I#$( even if you also provide +,S*funded dental services. %e&istration is a le&al re-uirement to practice.

%ees
&ou should also read our guidance for providers about fees' (his document is available on our website'

onfidential personal information

!lease ma)e sure that your application does not include any confidential personal information about the people who will use your service or your staff. This includes any information that can identify a person. #e will re.ect any application form that includes such information.

%illing in this form

/ou must fill in an answer to every field mar)ed with an asteris) "0$. 1ther fields are optional but if you have the information please provide it. #e will have to re.ect an incomplete application and return it. /ou must complete the declaration of compliance section. /ou can fill in and submit this form on paper or on a computer. If you fill it in on a computer you can submit it by attachin& it to an email2 this is the best way to ma)e applications to ,ealthcare Inspectorate #ales ",I#$. This form has been prepared as a 3protected4 #ord document. That means that if you use a computer you can easily move from answer to answer usin& your 3tab4( down arrow( and pa&e down )eys. /ou can also clic) from answer to answer usin& a mouse. /ou can put an 354 in chec)bo6es usin& your space bar or mouse. /ou can &o bac)wards to chan&e your answers usin& your pa&e up )ey( up arrow )ey( or mouse. Spell chec) and formattin& te6t with bullets cannot be used in protected #ord documents. If you want to chec) your spellin& or use bullets you can type the te6t into a blan) new document first( and then copy your te6t and paste it into the application form when you have finished. /ou can fill in this form on a computer usin& 37icrosoft #ord4 or 31pen 1ffice4. 1pen 1ffice is a free pro&ramme you can download from www.openoffice.or&. The spaces for answers increase in si8e if this is needed while you are typin&. If you are fillin& in this form on paper and need more space to answer any -uestions please submit additional clearly numbered sheets and mar) them with the -uestion number from this form.

ontents Data !rotection Act 9::' information Section 9: !ersonal Information Section 2: !ractice details Section =: Specialist services Section >: %ehabilitation of 1ffenders Act 9:?> Section ;: @alidatin& your photo&raph Section <: Application declaration Section ?: Application Aee ,ow to submit this application and accompanyin& documents

Page ; < ' 9 99 92 9= 9> 9;

)ata Protection Act 1**+ !nformation

#e will use the information provided within this form and any supportin& documentation submitted with your application to ma)e a decision about your application for re&istration. #e may need to verify some of the information you provide. #e may share information you &ive us as permitted by law( for e6ample with other re&ulatory bodies and law enforcement a&encies and with others within the #elsh Bovernment. The information you &ive us may also be sub.ect to disclosure under the Areedom of Information Act 2 . /our personal data may be used to: 7aintain a public re&ister of !rivate Dentists in accordance with the Care Standards Act 2 "as amended$. Arran&e a pro&ramme of inspections 7onitor compliance with re&ulatory re-uirements Ta)e enforcement action

Section 1, Personal !nformation

1'1 About "ou
0Title 0Airst name 7iddle name "s$ "if applicable$ 0Cast name !revious name "If applicable$ 0Date of Dirth "ddEmmEyy$ !lease list any other names by which you are )nown 0Bender "!lease tic)$ 0,ouse number or name 0Street 0TownECity 0County 0!ostcode 0Telephone number 7obile 0Fmail

7ale

Aemale

1'2 )ental -egistration

0BDC %e&istration +o. 0Date of first re&istration "ddEmmEyyyy$ 0Do you have any conditions imposed on your BDC %e&istrationG "!lease tic)$ If you answered yes to the -uestion above please provide details of the conditions. /es +o

0!lease confirm one of the followin&

I am currently included on a Dental !erformers list in #ales I am currently included on a Dental !erformers list in another UH country I have applied to a Dental !erformers list

0Details( includin& telephone number and address of performers list

0,ave you ever been removed( contin&ently removed( conditionally included( suspended or refused entry from any Dental !erformers listG If you answered yes to the above please provide further details 0,ave you( in the last = years( had any assessments underta)en by the Dental %eference ServiceG If you answered yes to the above please provide the date and address where the assessment was carried out

/es +o /es +o

Section 2, Practice )etails

2'1 Setting A
0+ame of establishmentEsettin& 0Duildin& +umber or +ame 0Street 0TownECity 0County 0!ostcode 0Telephone 0Aa6 0Fmail !lease confirm the followin& about the practice 0Can you be contacted at these premises by patientsG +ewly converted or refurbished facility F6istin& facility 7obile facility /es +o

If you are only practisin& in one practice please tic) here

2'2 Setting .
0+ame of establishmentEsettin& 0Duildin& +umber or +ame 0Street 0TownECity 0County 0!ostcode 0Telephone 0Aa6 0Fmail !lease confirm the followin& about the practice 0Can you be contacted at these premises by patientsG +ewly converted or refurbished facility F6istin& facility 7obile facility /es +o

2'3 Setting
0+ame of establishmentEsettin& 0Duildin& +umber or +ame 0Street 0TownECity 0County 0!ostcode 0Telephone 0Aa6 0Fmail !lease confirm the followin& about the practice 0Can you be contacted at these premises by patientsG +ewly converted or refurbished facility F6istin& facility 7obile facility /es +o

If you are practicin& in more than = practices please provide this information in the additional info section of this form.

Section 3, Specialist Services

3'1 Specialist services and clinical interests
!lease tic) below indicatin& which services "if any$ you provide( addin& any other clinical interests not listed Service Sedation Domiciliary visits Fndodontics Implants Advanced restorative or prosthodontics Clinical interests E other services "please specify$ NHS Private patients onl"

Section /, -ehabilitation of Offenders Act 1*0/

Due to the nature of an application for re&istration( applicants are e6empt from S.>"2$ of the %ehabilitation of 1ffenders Act 9:?>. %ehabilitation of 1ffenders Act 9:?; "F6emptions$ 1rder 9:?; "as amended$ provides that applicants are not entitled to withhold information about convictions which for the purposes are 3spent4 under the 9:?> Act. This means that ACC convictions must be declared even if they relate to offences many years previously. Aailure to disclose convictions I which would show up in any event on return of the DDS disclosure I could result in refusal or cancellation of re&istration. ,owever( a previous conviction does not necessarily mean that an applicant will not be considered a 3fit4 person for re&istration. /ou are invited below to declare any past criminal convictions re&ardless of how lon& a&o they occurred. 0>.9 ,ave you ever been convicted of an offence in a court of law or been cautioned in the UH or another countryG

/es +o

If you answered yes to the above please provide further details

0>.2 ,ave you ever been the sub.ect of a !olice investi&ationG

/es +o

If you answered yes to the above please provide further details

/'3 Please confirm one of the following,

I have applied for a DDS chec) with the +,S !erformers list I have enclosed a DDS form alon& with the relevant ori&inal documentation as stated on the front of the DDS form

Section 1, 2alidating "our photograph

/ou are re-uired to provide a recent photo&raph of yourself as part of this application for re&istration. That photo&raph must be validated by someone who has )nown you for at least two years. The person validatin& your photo&raph: 7ust not be related to you by birth or marria&e2 7ust not be in a personal relationship with you2 7ust not live at the same address2 7ust be resident in the UH.

If you are unable to meet the above re-uirements( you must follow these as closely as possible and enclose an e6planation of your reasons for non compliance with your application. The person validatin& your photo&raph must certify it is a true li)eness of you by writin& on the bac) of the photo&raph as follows: 3! certif" that this is a true li4eness of 5(itle and full name of applicant67 They must also si&n and date the bac) of the photo&raph and then complete the -uestion below.

1'1 (o be completed b" the person countersigning the applicants photograph

+ame Aull Address !rofession !lease tic) the bo6 to confirm that the enclosed photo&raph is a true li)eness of the applicant Si&nature Date +o. of years you have )nown the applicant

Section 8, Application declaration

I confirm that I am complyin& with( and will continue to comply with( the !rivate Dentistry "#ales$ %e&ulations 2 ' in relation to the provision of dental services and that the contents of this application form and any attached documents are true to the best of my )nowled&e and belief. I understand that the discovery of any deliberate concealment or omission of information could lead to any re&istration which may be &ranted as a result of this application bein& cancelled and may also render me liable to prosecution. I understand and accept that re&ulation 9' of the !rivate Dentistry "#ales$ %e&ulations 2 ' re-uires me to notify ,ealthcare Inspectorate #ales in writin& if any of the followin& events ta)e place or are proposed. Therefore( I will contact ,I# without delay if I: Cease to provide dental services2 or Chan&e my name2 or Chan&e my homeEpractice address"es$2 or Am convicted of or cautioned in respect of any offence other than a road traffic offence which is not punishable with imprisonment2 or ,ave any conditions imposed on my professional re&istration with the Beneral Dental Council or inclusion on a dental performers list.

I consent to ,I# ma)in& contact with any or&anisation it deems necessary to verify or validate any of the information in relation to my on&oin& re&istration.

If you are submittin& this form electronically we will accept a typed*in name as a si&nature.

0Applicant4s si&nature 0Applicant4s name 0Date "ddEmmEyy$ 0Fmail address 0%ole title

Section 0, Application %ee

Information on how much you need to pay can be found within the document 3Buidance on Aees !ayable by Independent ,ealthcare !roviders and !rivate Dentists %e&istered with ,ealthcare Inspectorate #ales4. This document would have been contained in the pac) sent to you or can be found at www.hiw.or&.u). If you are still unsure on the fee you can contact ,I# for confirmation.

Please confirm details of the application fee

Amount +ame of payee BDC +umber 7ode of payment "Che-ue or Card$

If you would li)e to pay by card you will need to download the payment form from www.hiw.or&.u). If you received a hard copy of the form a payment form should have been enclosed( if not please contact ,I# who can send a copy to you. 1r you can pay by che-ue "made payable to 3#elsh Bovernment4$ which you can enclose with your application. If you are submittin& your application by email but wish to pay by che-ue you should send this to the followin& address( with your name( BDC number and state that this is a new application on the bac) of the che-ue: Dental %e&istrations ,ealthcare Inspectorate #ales #elsh Bovernment %hydycar Dusiness !ar) 7erthyr Tydfil CA>' 9UJ

How to submit this application and accompan"ing documents

!lease submit this application to the ,ealthcare Inspectorate #ales( ma)in& sure that all re-uired additional forms and documents are included.

(he chec4list below lists the documents that "ou need to include with the application,
%orm or document !assport photo( countersi&ned and validated A fully completed DDS disclosure form( alon& with supportin& documentation and payment "if applicable$ )one

#here to send the application,

/ou should wherever possible email your completed form"s$ and accompanyin& documents to: H!#-egistration9wales'gsi'gov'u4 /ou must attach all the forms and documents to the same email. If you are unable to send us your application by email you should print and si&n your completed form"s$ and post them with any accompanyin& documents in the same envelope to: Dental %e&istrations ,ealthcare Inspectorate #ales #elsh Bovernment %hydycar Dusiness !ar) 7erthyr Tydfil CA>' 9UJ If you do not submit all re-uired forms and information your application will have to be returned to you. /ou can read more information on our website www.hiw.or&.u) or call 0300 082 +183.