Fraudulent Medication Reporting – Dental Practice/Dental Out of Hours | Counter Fraud and Probity Services (CFPS)

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INSTRUCTIONS

Please use the form below if you work in a dental practice or dental out of hours facility and you wish to report an occurrence of prescription fraud. To assist with our enquiries please provide as much information as possible.

SUPPORTING DOCUMENTS

Guidance on the reporting, recording and investigation of prescription fraud for:

Dental Practices

Dental Out of Hours

1

2 Section A - Contractor Details

3 Section B - Patient Details

4 Section C - Details of Incident

5 Section D - Dispensing Details

6 Submit

Contact Number
Please provide a direct contact number for the person reporting this incident.
Reporter's Name
Position
Date CFPS Contacted*

DD
MM
YYYY
Time CFPS Contacted*

: HH

MM

Section A - Contractor Details:
- Dental Practice
- Out of Hours
Contractor Name
Contractor Address
Town
Postcode
Practice Number
Telephone No
Email Address

Section B - Patient Details:
Patient Forename*
Patient Surname*
Any alias (if known)
Patient DOB
OR Approx Age
Address
Town
Postcode
Patient HCN/CHI
Phone Number
Mobile
Description of patient:
Height
Build/Weight
Distinguishing features
Hair Colour
Hair Style
Ethnic Group*
Gender*
Vehicle details
Is the patient registered with the Practice?
- Yes
- No

Section C - Details of Incident:
Nature of Incident*
Date of incident
Further details
Have PSNI been informed?*
- Yes
- No
Crime Reference Number
Is CCTV footage available?
- Yes
- No
If Yes, please save a copy to disc *

* Please note the BSO are not liable for any costs incurred in retrieving CCTV footage

Section D - Prescribing Details:
Was medication prescribed/dispensed?
- Yes
- No
- N/A
If yes, please detail each drug name, quantity and strength
Do you have access to the original or a copy of the prescription?
- Yes
- No
- N/A
Was any medication requested that was not prescribed/dispensed?
- Yes
- No
If yes, please detail each drug name, quantity and strength

Any further comments:
Phone
This field is for validation purposes and should be left unchanged.

CONTACT US

Counter Fraud Services
Business Services Organisation
2 Franklin Street
BELFAST
BT2 8DQ

T : 028 9536 3839
E : cfs@hscni.net

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