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

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