1 Application form Dental Care Professionals and Practice Managers
2 2 Dental Care Professionals and Practice Managers Please print your answers clearly, using a black or blue pen. Please complete all sections of this form, read the declaration and agreement on page 10 and sign the statement at the bottom of page 3. Incomplete or unsigned forms cannot be processed and will be returned. If you require any help completing this form please contact us. Call our freephone membership helpline: Lines are open 8am to 6pm, Mon-Fri (except bank holidays). or Visit our website theddu.com/liaison for details of your local DDU liaison manager. Before returning this form to us check you have: completed each relevant section completed your payment choice signed the statement on page 3 3 Return the completed form to: FREEPOST MDU SERVICES LIMITED.
4 4 Dental Care Professionals and Practice Managers E General questions Please tick relevant answer Please read questions E1 to E11 carefully. Any misrepresentation or omission of information may lead to the rejection of your application, subsequent termination of membership or withdrawal or denial of benefits. If in doubt, tick yes If you answer yes to any question, please provide details on page 5 including: question number relevant dates the nature of the matter in question how the matter was resolved whether you were assisted by an insurer, medical defence organisation or other body E1 Are you aware of any incidents or circumstances involving you, irrespective of their seriousness, which could lead to an investigation, complaint, claim, disciplinary action, legal dispute, suspension from practice, imposition of restrictions or conditions on your registration or licence to practise, or your removal from a professional register or of your licence to practise, by a registration body? E2 Have you, in the last 10 years, had any complaints or claims brought or threatened against you, irrespective of their merits or seriousness? E3 Have any concerns ever been raised about your conduct, clinical practice or performance, educational progress, business administration or probity by an employer, dental school, HS trust, clinical colleague or any other body? (e.g. the Care Quality Commission or a private hospital) E4 Have you ever been the subject of an investigation or action under a disciplinary process or the HS Performers List Regulations, irrespective of the merits or seriousness of the matter that led to this? E5 Have you ever been suspended or dismissed from a post or had practice privileges or hospital admitting rights withdrawn, suspended or made subject to restrictions or conditions? E6 Have you ever been the subject of an investigation or an adverse finding by a registration or licensing body? (e.g. GDC/GMC) or any other body, e.g. the ational Clinical Assessment Service or a Royal College E7 Have you ever had restrictions or conditions imposed on your registration or licence to practise, or been removed, refused or erased from registration or had a licence to practise withdrawn or refused, by a registration or licensing body? E8 Have you ever been charged with, or convicted of, a criminal offence, or received a formal Police Caution? (Including any motoring offence even if you were fined but not imprisoned but excluding fixed penalty notices for speeding offences or parking tickets. ou should not disclose any cautions or convictions which are protected under the 2013 amendment to the Rehabilitation of Offenders Act 1974 Exceptions Order 1975) E9 Has any professional indemnity insurer or medical defence organisation ever declined to indemnify you, required special terms to indemnify you, cancelled or refused to renew your policy or membership or charged you an additional premium/subscription? E10 Have you ever been bankrupt or subject to insolvency proceedings, or entered into or proposed any voluntary arrangement with creditors? E11 Are there any other facts or circumstances that may be relevant to our considering your application? If so, please provide details.
5 Dental Care Professionals and Practice Managers 5 Additional information for section E Question number Please continue on a separate sheet if necessary.
6 6 Dental Care Professionals and Practice Managers F Work circumstances Please note your subscription will be based on the average number of sessions you work in a week. A session is each 4 hours or part of 4 hours worked. To calculate your average weekly sessions take the average number of hours you work per year, divide it by 52 and then divide by 4. The DDU does not currently provide indemnity to dental care professionals carrying out botulinum toxin and collagen replacement therapy, and all similar cosmetic procedures. F1 Please tick the type of work you undertake and indicate the number of sessions worked per week, where required. ou may tick more than one option. Practice owner A Practice owner is defined by the DDU as a person who does any of the following: Employs any staff who work in a dental practice. Commissions clinical services to be provided in a practice by other GDC registered dental professionals. Owns or runs a dental practice or a clinical facility, either as a sole practitioner or with others. A Dental Director of a Dental Body Corporate, or a partner in a limited liability or other dental practice partnership, including expense sharing partnerships. Registered provider with the CQC. An independent contractor provider of HS General Dental Services to a Primary Care Commissioning body or Health Board (does not include dentists employed directly by the Primary Care Commissioning body or Health Board). Practice manager Dental nurse Dental technician Orthodontic therapist Clinical dental technician Sessions per week Sessions per week Do you undertake Implant Retained Dentures? Dental hygienist and/or therapist If you have ticked dental hygienist/therapist, please complete the following: Are you indemnified by your employer? If no, do you want access to indemnity from the DDU? If yes, for how many sessions per week Dental hygienist Sessions per week Dental therapist Sessions per week Do you undertake tooth bleaching? If yes, please provide details of any training undertaken F2 Do you perform any of the following? E-consultations Giving advice over the internet Online prescribing (i.e. prescribing over the internet) Other telehealth work If yes, to any of the above, do you require access to indemnity from the DDU? If yes, please give full details, making sure to include the location of the patients (country), whether you are prescribing, any website address linked with this work (if relevant) and how may hours/patients per week.
7 Dental Care Professionals and Practice Managers 7 F3 Do you have any other clinical work for which you require access to indemnity? If yes, please provide full details continuing in the space below, if necessary. F4 Do you do anything which is not classified as normal for your specialty/group, for which you require access to indemnity and about which you have not already told us? If yes, please provide full details continuing in the space below, if necessary. F5 Do you work in any of the following regions? o es, all of my work es, some of my work Jersey Guernsey Isle of Man Scotland F6 Do you do any work outside of the UK? (Including the Republic of Ireland) If yes, do you require access to indemnity from the DDU? If yes, please phone the membership team to discuss your work. G Why have you chosen to apply for DDU membership? Please tick all that apply Subscription rates Personal recommendation Dissatisfaction with previous indemnity provider Dental Advantage Please provide your Dental Advantage number Other (please give details in space provided) H I Services text alerts We can send important text alerts to your mobile phone provided you have given us your mobile number on page 3. Please indicate below if you would like to opt in to text alerts. ou can stop text alerts at any time in the My membership section of our website. otification regarding your DDU renewal Additional information for section F Question number
8 8 Dental Care Professionals and Practice Managers J Paying your subscription our prospective membership will commence from the date that your completed application form is received by our membership department unless you specify a start date after this. This does not constitute acceptance of your membership, however, we will notify you if and when this is successful. Should you require your prospective membership to commence from today, please complete the Get a quote form at theddu.com/quote, or call the freephone membership helpline on Lines are open Mon to Fri, 8am to 6pm (except bank holidays). Date membership to commence: Immediately: Future date: D D M M Please be aware that subject to the information you provide and the date you submit your application, your subscription rate may change. If this is the case you will be informed prior to being accepted into membership. Please note that processing of your payment does not constitute acceptance of your application for membership. our payment will be refunded if your application is not successful. For your peace of mind we recommend you pay by Direct Debit and we have two options for your convenience. We can debit your account the full amount each year (see section K), or you can pay in monthly instalments by way of an agreement provided by Premium Credit Limited (see section L). ou only need to fill in the relevant mandate once and it will roll over from year to year. ou are protected by the Direct Debit safeguards and can cancel your authority at any time by contacting your bank or building society. For annual Direct Debit (single annual payment of full amount) please complete section K. For other payment options see sections L and M overleaf. K Annual Direct Debit payment option (Single annual payment of full amount) Annual Direct Debit mandate. Instructions to your bank/building society to pay by Direct Debit: Please complete parts K1-K4 to make payments directly from your account K1 Full name and postal address of bank/building society - including postcode: Postcode (required): K2 K3 ame of the account holder Bank/building society account number: Bank/building society sort code: Originator s identification number: K4 our instruction to the bank/building society and signature: I instruct you to pay Direct Debits from my account at the request of MDU Services Limited The amounts are variable and may be debited on various dates I understand that MDU Services Limited may change the amounts and dates only after giving me prior notice I will inform the bank/building society in writing if I wish to cancel this instruction I understand that if any Direct Debit is paid which breaks the terms of the instructions, the bank/building society will make a refund Signature Date D D M M Direct Debit Guarantee This guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit MDU Services Limited will notify you 5 working days in advance of your account being debited or as otherwise agreed. If you request MDU Services Limited to collect a payment, confirmation of the amount and date will be given to you at the time of the request. If an error is made in the payment of your Direct Debit, by MDU Services Limited or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society. - If you receive a refund you are not entitled to, you must pay it back when MDU Services Limited asks you to. ou can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.
9 Dental Care Professionals and Practice Managers 9 L Monthly payments option (available for subscriptions over 50) Monthly instalments (no immediate payment is required). Have you incurred more than three CCJs against you within the last two years that have not been satisfied? Please choose an alternative payment option We will contact you once your application has been processed to set this up Please note that if you choose to pay by monthly instalments, Premium Credit Limited may apply a small interest charge. Details will be provided to you prior to any monies being taken. Payment will be taken over 10 months. Please do not complete the annual Direct Debit mandate as this only applies to single annual payment of the full amount M Alternative payment options Cheque. Please enclose a cheque made payable to MDU Services Ltd. Debit/credit cards. Single annual payment of full amount. We will contact you for payment once your application has been processed. Please ensure you have provided your telephone number in section A.
11 Dental Care Professionals and Practice Managers 11 Before returning this form to us check you have: completed each relevant section completed your payment choice signed the statement on page 3 3 Return the completed form to: FREEPOST MDU SERVICES LIMITED.
12 How to contact us Membership t e Advisory t e our feedback Give us your feedback about the DDU theddu.com/feedback Website Have you got our app? The Dental Defence Union (DDU) is the specialist dental division of The Medical Defence Union Limited (MDU) and references to the DDU and DDU membership mean the MDU and membership of the MDU. MDU Services Limited (MDUSL) is authorised and regulated by the Financial Conduct Authority for insurance mediation and consumer credit activities only. MDUSL is an agent for The Medical Defence Union Limited (MDU). MDU is not an insurance company. The benefits of MDU membership are all discretionary and are subject to the Memorandum and Articles of Association. MDU Services Limited, registered in England Registered Office: One Canada Square, London E14 5GS GDP Application form dcp
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