Denplan Leaving Form 64523w

Changing your Denplan dentist

Changing your dentist under Denplan If you are moving house, going to college or if there is a change in your circumstances, you may need to change your dentist. As your Denplan care contract is between you and your dentist and is non-transferable, please follow the simple steps below to ensure a smooth transition.

Action plan for a smooth transition to a new dentist • Arrange a leaving appointment – This will enable the dentist to finish any outstanding treatment needed, where appropriate • Ask the dentist to complete a Patient Leaving form – You will need to give this to the new dentist. This will give them valuable information about your past dental history • Write to or telephone Denplan to cancel the existing contract giving at least 21 days notice – You need to end the contract with the present dentist. The contract will expire on the last day of the month, after your 21 days notice has finished. Supplementary Insurance cover will end on the same date

Action plan for a smooth transition to a new dentist • Re- with a new Denplan dentist – Denplan can send you a list of Denplan dentists in your local area at your request, or you can search for a new dentist using the Find a Dentist facility on our website: www.denplan.co.uk

Please to give the new dentist the completed Patient Leaving form.

• Check if there will be an examination fee for a new patient registration – Check this before booking an initial appointment with the new dentist as this can vary from practice to practice • Complete a new application form and Denplan contract at the initial appointment with the new dentist – If you re- on to Denplan within six months of ending the previous registration, you can re- with Denplan free of charge. The application form is sent to Denplan so that we can update our records and start collecting payments on the new dentist’s behalf. You do not need to change your Direct Debit instruction unless your previous bank details have changed or your contract has lapsed.

• Check your monthly fee – Each Denplan dentist sets their own fees, so the new dentist may charge a different fee. However, as part of the total monthly payment 90p represents the s for the Supplementary Insurance provided by AXA PPP healthcare Limited which includes Insurance Tax at 5% (excluding residents of the Channel Islands and the Isle of Man) and 39p is the fee payable to Denplan for providing Insurance Services. This cost is the same for all Denplan patients • Note the date the contract ends with your previous dentist – Arrange for your new contract to commence after your previous contract ends. This will help you to avoid over-lapping registrations and double payments • Check that your dentist is happy with your treatment needs – : Clinical opinion between dentists can and do vary. The new dentist may have a different opinion of your treatment needs, and there may be a difference in what is included and/or excluded from your contract



Please note:

• Your Supplementary Insurance and Insurance Services will re-commence once you have ed with a new dentist. The commencement date will be advised to you in the confirmation letter we send to you • You may end the contract (including your Supplementary Insurance and Insurance Services) by ing Denplan within the cancellation period, which is 14 days following conclusion of your contract

Questions? Need further advice? Please call our Customer Advisor Team on:

0800 401 402

Denplan Patient Leaving Form

Current preventive care programme – including recall interval and long term aims

Dentist copy Please keep this form for your records Patient’s details Title Date of birth

Mr

Mrs D

Ms

D

Miss

M M

Y

Y

D

M M

Y

Y

Y

Y

D

D

M M

Y

Y

Y

Y

Date of last radiographs

Other Y

Date of last routine examination D

Y

History of Oral Health Scores© (if Denplan Excel Accredited dentist)

First name

Score

Surname

Score

Denplan Registration No.

Score

Registration date D

D

M M M M

A B C Category

D

Score

YY YY YY YY E



Date D

D

M M

Y

Y

Y

Y

Date D

D

M M

Y

Y

Y

Y

Date D

D

M M

Y

Y

Y

Y

Date D

D

M M

Y

Y

Y

Y

Radiographic report

Point score

Exclusions to contract, if any

Outstanding treatment (if any) and reason (All treatment should be completed before the patient leaves your care)



Hard tissues – please comment on condition of restorations and tooth surface loss



Treatment declined (if any) with comments



details should you wish to discuss any aspects of the patient’s dental history.

Soft tissues/mucosal lesions – please comment

Trauma history (if any) and relevance to on-going treatment needs

Telephone  hip No. Are you a Denplan Excel Accredited dentist? Yes



Date of patient’s leaving examination D BPE

Date D

D

M M

Y

Y

Y

Y

D

No



M M



Y

Y

Y

Y I confirm that the named

patient was in a reasonable state of dental health except as noted above Dentist’s name

Dentist’s signature Date 7 DD DD

M M M M

Y

Y

Y

Y

Denplan Patient Leaving Form

Current preventive care programme – including recall interval and long term aims

Patient copy to be completed by your dentist Please keep this form and give it to your new dentist Patient’s details Title Date of birth

Mr

Mrs D

Ms

D

Miss

M M

Y

Y

D

M M

Y

Y

Y

Y

D

D

M M

Y

Y

Y

Y

Date of last radiographs

Other Y

Date of last routine examination D

Y

History of Oral Health Scores© (if Denplan Excel Accredited dentist)

First name

Score

Surname

Score

Denplan Registration No.

Score

Registration date D

D

M M M M

A B C Category

D

Score

YY YY YY YY E



Date D

D

M M

Y

Y

Y

Y

Date D

D

M M

Y

Y

Y

Y

Date D

D

M M

Y

Y

Y

Y

Date D

D

M M

Y

Y

Y

Y

Radiographic report

Point score

Exclusions to contract, if any

Outstanding treatment (if any) and reason (All treatment should be completed before the patient leaves your care)



Hard tissues – please comment on condition of restorations and tooth surface loss



Treatment declined (if any) with comments



details should you wish to discuss any aspects of the patient’s dental history.

Soft tissues/mucosal lesions – please comment

Trauma history (if any) and relevance to on-going treatment needs

Telephone  hip No. Are you a Denplan Excel Accredited dentist? Yes



Date of patient’s leaving examination D BPE

Date D

D

M M

Y

Y

Y

Y

D

No



M M



Y

Y

Y

Y I confirm that the named

patient was in a reasonable state of dental health except as noted above Dentist’s name

Dentist’s signature Date 7 DD DD

M M M M

Y

Y

Y

Y

Denplan Limited, Denplan Court, Victoria Road, Winchester, SO23 7RG, UK. Tel: +44 (0) 1962 828000. Fax: +44 (0) 1962 840846. Email: [email protected] ed in England No. 1981238. ed address Hambleden House, Waterloo Court, Andover, Hampshire SP10 1LQ. PREG05 03-12

Part of Simplyhealth, Denplan Limited is an Appointed Representative of Simplyhealth Access which is authorised and regulated by the Financial Services Authority. This information can be checked by visiting the FSA which is on their website: www.fsa.gov.uk or by ing the FSA on 0845 606 1234. Denplan Limited is regulated by the Jersey Financial Services Commission. This policy is underwritten by AXA PPP healthcare Limited. Denplan Limited only arranges dental insurance from Simplyhealth Access and AXA PPP healthcare Limited. s received are held by Denplan as agent of the insurer. Your calls may be recorded and monitored for training and quality assurance purposes.