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

October 2013

Applications under section 12 of Care Standards Act 2000

This form must only be used by:

Individuals applying to register as a dentist providing NHS and private treatmentIt must not be used by:

Dentists who provide private only treatment.

Why do I need to complete this form?Under the Care Standards Act 2000 and the Private Dentistry (Wales) Regulations 2008, dentists undertaking any private or non-NHS funded work in Wales are required to register with Healthcare Inspectorate Wales (HIW), even if you also provide NHS-funded dental services. Registration is a legal requirement to practice.

FeesYou should also read our guidance for providers about fees. This document is available on our website.

Confidential personal information

Please make 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. We will reject any application form that includes such information.

Filling in this form

You must fill in an answer to every field marked with an asterisk (*). Other fields are optional but if you have the information please provide it. We will have to reject an incomplete application and return it.

You must complete the declaration of compliance section.

You 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 attaching it to an email; this is the best way to make applications to Healthcare Inspectorate Wales (HIW).

This form has been prepared as a ‘protected’ Word document. That means that if you use a computer you can easily move from answer to answer using your ‘tab’, down arrow, and page down keys. You can also click from answer to answer using a mouse. You can put an ‘X’ in checkboxes using your space bar or mouse. You can go backwards to change your answers using your page up key, up arrow key, or mouse.

Spell check and formatting text with bullets cannot be used in protected Word documents. If you want to check your spelling or use bullets you can type the text into a blank new document first, and then copy your text and paste it into the application form when you have finished.

You can fill in this form on a computer using ‘Microsoft Word’ or ‘Open Office’. Open Office is a free programme you can download from www.openoffice.org. The spaces for answers increase in size if this is needed while you are typing.

If you are filling in this form on paper and need more space to answer any questions please submit additional clearly numbered sheets and mark them with the question number from this form.

Contents Page

Data Protection Act 1998 information 5Section 1: Personal Information 6Section 2: Practice details 8Section 3: Specialist services 10Section 4: Rehabilitation of Offenders Act 1974 11Section 5: Validating your photograph 12Section 6: Application declaration 13Section 7: Application Fee 14How to submit this application and accompanying documents 15

Data Protection Act 1998 Information

We will use the information provided within this form and any supporting documentation submitted with your application to make a decision about your application for registration. We may need to verify some of the information you provide.

We may share information you give us as permitted by law, for example with other regulatory bodies and law enforcement agencies and with others within the Welsh Government. The information you give us may also be subject to disclosure under the Freedom of Information Act 2000.

Your personal data may be used to:

Maintain a public register of Private Dentists in accordance with the Care Standards Act 2000 (as amended).

Arrange a programme of inspections Monitor compliance with regulatory requirements Take enforcement action

Section 1: Personal Information

1.1 About you*Title      

*First name      

Middle name (s) (if applicable)

     

*Last name      

Previous name (If applicable)

     

*Date of Birth (dd/mm/yy)      

Please list any other names by which you are known

     

*Gender (Please tick) Male Female

*House number or name      

*Street      

*Town/City      

*County      

*Postcode      

*Telephone number      

Mobile      

*Email      

1.2 Dental Registration*GDC Registration No.      

*Date of first registration (dd/mm/yyyy)      

*Do you have any conditions imposed on your GDC Registration? (Please tick)

Yes No

If you answered yes to the question above please provide details of the conditions.

*Please confirm one of the following

I am currently included on a Dental Performers list in Wales

I am currently included on a Dental Performers list in another UK country

I have applied to a Dental Performers list

*Details, including telephone number and address of performers list

*Have you ever been removed, contingently removed, conditionally included, suspended or refused entry from any Dental Performers list?

Yes No

If you answered yes to the above please provide further details      

*Have you, in the last 3 years, had any assessments undertaken by the Dental Reference Service?

Yes No

If you answered yes to the above please provide the date and address where the assessment was carried out

Section 2: Practice Details

2.1 Setting A*Name of establishment/setting      

*Building Number or Name      

*Street      

*Town/City      

*County      

*Postcode      

*Telephone      

*Fax      

*Email      

Please confirm the following about the practice

Newly converted or refurbished facility Existing facility Mobile facility

*Can you be contacted at these premises by patients?

Yes No

If you are only practising in one practice please tick here

2.2 Setting B *Name of establishment/setting      

*Building Number or Name      

*Street      

*Town/City      

*County      

*Postcode      

*Telephone      

*Fax      

*Email      

Please confirm the following about the practice

Newly converted or refurbished facility Existing facility Mobile facility

*Can you be contacted at these premises by patients?

Yes No

2.3 Setting C*Name of establishment/setting      

*Building Number or Name      

*Street      

*Town/City      

*County      

*Postcode      

*Telephone      

*Fax      

*Email      

Please confirm the following about the practice

Newly converted or refurbished facility Existing facility Mobile facility

*Can you be contacted at these premises by patients?

Yes No

If you are practicing in more than 3 practices please provide this information in the additional info section of this form.

Section 3: Specialist Services

3.1 Specialist services and clinical interests

Please tick below indicating which services (if any) you provide, adding any other clinical interests not listed

Service NHS Private patients onlySedationDomiciliary visitsEndodonticsImplantsAdvanced restorative or prosthodontics

Clinical interests / other services (please specify)

Section 4: Rehabilitation of Offenders Act 1974

Due to the nature of an application for registration, applicants are exempt from S.4(2) of the Rehabilitation of Offenders Act 1974. Rehabilitation of Offenders Act 1975 (Exemptions) Order 1975 (as amended) provides that applicants are not entitled to withhold information about convictions which for the purposes are ‘spent’ under the 1974 Act. This means that ALL convictions must be declared even if they relate to offences many years previously. Failure to disclose convictions – which would show up in any event on return of the DBS disclosure – could result in refusal or cancellation of registration. However, a previous conviction does not necessarily mean that an applicant will not be considered a ‘fit’ person for registration. You are invited below to declare any past criminal convictions regardless of how long ago they occurred.

*4.1 Have you ever been convicted of an offence in a court of law or been cautioned in the UK or another country?

Yes No

If you answered yes to the above please provide further details

     

*4.2 Have you ever been the subject of a Police investigation? Yes

No

If you answered yes to the above please provide further details

     

4.3 Please confirm one of the following:I have applied for a DBS check with the NHS Performers list

I have enclosed a DBS form along with the relevant original documentation as stated on the front of the DBS form

Section 5: Validating your photograph

You are required to provide a recent photograph of yourself as part of this application for registration. That photograph must be validated by someone who has known you for at least two years.

The person validating your photograph:

Must not be related to you by birth or marriage; Must not be in a personal relationship with you; Must not live at the same address; Must be resident in the UK.

If you are unable to meet the above requirements, you must follow these as closely as possible and enclose an explanation of your reasons for non compliance with your application.

The person validating your photograph must certify it is a true likeness of you by writing on the back of the photograph as follows:

‘I certify that this is a true likeness of [Title and full name of applicant]’

They must also sign and date the back of the photograph and then complete the question below.

5.1 To be completed by the person countersigning the applicants photographName      

Full Address     

Profession      

Please tick the box to confirm that the enclosed photograph is a true likeness of the applicant

Signature     

Date      

No. of years you have known the applicant      

Section 6: Application declaration

I confirm that I am complying with, and will continue to comply with, the Private Dentistry (Wales) Regulations 2008 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 knowledge and belief.

I understand that the discovery of any deliberate concealment or omission of information could lead to any registration which may be granted as a result of this application being cancelled and may also render me liable to prosecution.

I understand and accept that regulation 18 of the Private Dentistry (Wales) Regulations 2008 requires me to notify Healthcare Inspectorate Wales in writing if any of the following events take place or are proposed. Therefore, I will contact HIW without delay if I:

Cease to provide dental services; or Change my name; or Change my home/practice address(es); or Am convicted of or cautioned in respect of any offence other than a road traffic offence

which is not punishable with imprisonment; or Have any conditions imposed on my professional registration with the General Dental

Council or inclusion on a dental performers list.

I consent to HIW making contact with any organisation it deems necessary to verify or validate any of the information in relation to my ongoing registration.

If you are submitting this form electronically we will accept a typed-in name as a signature.

*Applicant’s signature      

*Applicant’s name      

*Date (dd/mm/yy)      

*Email address      

*Role title      

Section 7: Application Fee

Information on how much you need to pay can be found within the document ‘Guidance on Fees Payable by Independent Healthcare Providers and Private Dentists Registered with Healthcare Inspectorate Wales’. This document would have been contained in the pack sent to you or can be found at www.hiw.org.uk. If you are still unsure on the fee you can contact HIW for confirmation.

Please confirm details of the application fee

Amount      

Name of payee      

GDC Number      

Mode of payment (Cheque or Card)

     

If you would like to pay by card you will need to download the payment form from www.hiw.org.uk. If you received a hard copy of the form a payment form should have been enclosed, if not please contact HIW who can send a copy to you.

Or you can pay by cheque (made payable to ‘Welsh Government’) which you can enclose with your application. If you are submitting your application by email but wish to pay by cheque you should send this to the following address, with your name, GDC number and state that this is a new application on the back of the cheque:

Dental RegistrationsHealthcare Inspectorate WalesWelsh GovernmentRhydycar Business ParkMerthyr TydfilCF48 1UZ

How to submit this application and accompanying documents

Please submit this application to the Healthcare Inspectorate Wales, making sure that all required additional forms and documents are included.

The checklist below lists the documents that you need to include with the application:

Form or document Done

Passport photo, countersigned and validated

A fully completed DBS disclosure form, along with supporting documentation and payment (if applicable)

Where to send the application:

You should wherever possible email your completed form(s) and accompanying documents to: HIWRegistration@wales.gsi.gov.uk

You 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 sign your completed form(s) and post them with any accompanying documents in the same envelope to:

Dental RegistrationsHealthcare Inspectorate WalesWelsh GovernmentRhydycar Business ParkMerthyr TydfilCF48 1UZ

If you do not submit all required forms and information your application will have to be returned to you.

You can read more information on our website www.hiw.org.uk or call 0300 062 8163.