Online Dental Claim

1. Checklist - Prior to Completing

Checklist*
Is this claim within 3 months of the date of treatment?
Have you the appropriate receipts?
Have you sufficient benefit available for this claim?

Please also ensure that you also have the following available to complete your claim

Policy number

Dentist/Practitioner details

Personal bank details

If you have any problems with completing this form please contact us on 01204 555047. Lines are open Monday to Friday 9am to 5pm.

2. Make Your Claim

Policy Holder

Name*

Policy Number*

Date of Birth*

Contact Number*

Address*

Post Code*

Email*

Your Dentist/Practitioner

Dentist's Name*

Dentist's Address*

Dentist's Telephone Number*

Treatment Claimed For

What Treatment Have You Had Completed?

PLEASE NOTE: If the amount you are claiming is not shown in the drop downbox below please click on the following link to complete a paper based form CLICK HERE

Amount Claimed*

Date Advised Treatment Required*

Date of Previous Dental Examination*

Upload Your Receipt/s*

I confirm the below statements apply for document I uploaded:*
The receipt must be in the name of the person claiming
Details of the treatment must be outlined
Details of the practitioner performing the treatment must be provided
The date of the treatment must be provided

For any claim submitted online Bolton and District Hospital Saturday Council reserve the right to request original receipts prior to processing, as part of it's rigorous anti-fraud measures.

Are You Claiming For Accident and Emergency Treatment
Yes
No

Accident/Emergency

Description of Incident and What Symptoms Did You Suffer

Type of Treatment

Date of Accident

Date of Treatment

Did The Accident Involve Anyone You May Be Claiming Against?
Yes
No

Payments

For payment to be paid directly into your own bank account then please complete the details below:

Account Name

Sort Code

Account Number

Data Protection Act 1988

Information about health, medical history and any treatment that you have is sensitive personal information.

Usually we need your consent to process your personal information.

You have a right to receive details of the information we hold about you. We may make a small charge. We may ask for dental information via your dentist.

If on reading a dental record you believe it is inaccurate or misleading you can request that an amendment is attached to it.

You may request from us, in writing, a copy of any personal information contained in any independent report that we obtain.

You should contact your own dentist for any report they produce.

We send claims correspondence to the policyholder unless we are advised to do otherwise.

Prevention & Detection of Crime

Please note that your insurance policy with us is based on mutual trust. If we are suspicious that any claim may be fraudulent we have rigorous anti-fraud measures in place. These may include auditing the records of medical practitioners to prove that our customers are correctly billed for the services received effectively to prevent and detect crime. This may also involve auditing the policyholder's medical and health records before of after treatment. We may need to share information received with third parties such as the General Medical Council or the NHS Counter-Fraud Security Management Service as we deem appropriate. We may also be required by law to submit information to law enforcement agencies about our suspicions of fraudulent claims and other crime.

Policy Declaration

I confirm that

The treatment detailed on the invoice submitted has been paid in full

I have received a dental examination during the twelve months prior to the date of joining this scheme and that all remedial treatment was completed at that time

The treatment was not planned prior to the date of joining

The information provided is to the best of my knowledge true and correct

Declaration*
I confirm the above 4 statements