Provider Information

Step 1 of 5

Provider name

Contract number

Provider address

Email address of Provider

Please give details of any other addresses associated with this contract

Payment Responsibility

Step 2 of 5

Are you solely responsible for payment of this demand?

Yes

No

Details of all those responsible and percentages

Name

Contract Number

Percentage of bill

Provider's declaration

I confirm there is no reimbursement for business rates included within the contract payment.

To enable the NHS to prevent and detect fraud and incorrectness, I consent to the disclosure of relevant information to and by the NHS Business Services Authority, NHS England, Department of Work & Pensions, HM Revenue & Customs and local authorities.

Claim Details

Step 3 of 5

NHS % (proportion of gross income from NHS treatments at this property)

Please give, as a percentage, the proportion of your gross income from the provision of dental services (i.e. from both NHS and private work) at this property, that comes from NHS treatments.

Value of council demand

How is the bill paid?

Monthly instalments

One lump sum

1st Half year

2nd Half year

First day of reimbursement period

Total reimbursement requested

Small Business Rate Relief (SBRR)

For information on Small Business Rate Relief (SBRR), you can visit the Valuation Office Agency (VOA) website www.voa.gov.uk

SBRR has been claimed for this property

SBRR has not been claimed for this property

If not claimed, please indicate reason

Rateable value of property exceeds limit

SBRR has been claimed on another property

Other

Please give details

Supporting Documents and Declaration

Step 4 of 5

NHS % (previous financial year with evidence)

Evidence showing the NHS proportion claimed in the previous financial year for which you have full accounts. Your evidence can be a set of accounts or a letter from a certified accountant.

Warning Supporting documents required

You must provide the following supporting documents:

Evidence showing the NHS proportion claimed in the previous financial year for which you have full accounts. Your evidence can be a set of accounts or a letter from a certified accountant.
A copy of the demand notice.
Relevant receipts if claiming payment in one lump sum or two half yearly payments.

Please do not submit original documents as these will not be returned

Date

Signature of Provider

If signing on behalf of a corporate body please print name

Review your application

Step 5 of 5

Warning By submitting this application you are confirming that the information you have given is correct and complete.

Email the completed form with any necessary documentation to:

nhsbsa.dentalservices@nhsbsa.nhs.uk

or post to:

NHSBSA Patient Services
SFE Payments Team
Bridge House
152 Pilgrim Street
Newcastle
NE1 6SN

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