Monthly Superannuation Notification

CONTRACT
Mrs ST TARIQ
EVD Canning Town QMF 1017730000
East Village Dental Canning Town NILESH PATEL
6 - 7 Rathbone Market If you have any queries please call the NHS
Barking Road Dental Services Helpdesk on 0300 330 1348 or
E16 1EH email nhsbsa.dentalservices@nhsbsa.nhs.uk

112881

1
NATIONAL HEALTH SERVICE

Contract QMF 1017730000

Statement Reference 2223/12 NILESH PATEL

Performer 112881
Date 01/04/23 MRS ST TARIQ

Information only

MONTHLY SUPERANNUATION NOTIFICATION

Payments Deductions
Financial Details
Monthly Payment £2,554.94
Patients' Charges £5,645.20
Remissions Total £2,956.80
Performer Contributions
Superannuation Contribution @ 5.10% £130.30
Employer's Contribution (for information) £367.40
Employer's Contribution @ 14.38% £367.40
Sub Totals £5,511.74 £5,775.50
Net Total -£263.76

OTHER FINANCIAL ACTIVITY DURING THE PERIOD

Description Receipts Payments Deductions
Note that receipts will not appear above until the payment has been cleared

2
NATIONAL HEALTH SERVICE

Contract QMF 1017730000

Statement Reference 2223/12 NILESH PATEL

Performer 112881
Date 01/04/23 MRS ST TARIQ

Information only

FORMS PROCESSED (21/02/2023 - 22/03/2023)

Patient Sex DOB Band UDA/UOA Patients' Charge £ Comments
Abedin S F 30.10.16 2b 5.00 CRN 015386
Prescription Only Ignored
Aboo I M 16.08.11 2b 5.00 CRN 014880
No Ethnic Origin
Aboo K F 27.11.18 01 1.00 CRN 014881
No Ethnic Origin
Abu K M 12.07.69 01 1.00 CRN 016373
Tax Credits
Agyeman A F 27.01.88 2a 3.00 65.20 CRN 014998
Prescription Only Ignored
Agyeman A F 27.01.88 2a -3.00 -65.20 CRN 014998
Replaced as Requested
Agyeman A F 27.01.88 2a 3.00 65.20 CRN 014998
Prescription Only Ignored
Schedule Query
Ahmed A F 30.05.14 01 1.00 CRN 016394
Ahmed A F 16.07.17 2b 5.00 CRN 016395
Akhtar K M 06.09.76 2b 5.00 65.20 CRN 014783
Akther S F 02.12.75 01 1.00 CRN 016391
Tax Credits
Ali L F 01.06.01 2b 5.00 CRN 015144
Universal Credit
Amoakoyeboah K F 18.04.97 2a 3.00 65.20 CRN 014634
Avilacastillo S F 19.05.20 01 1.00 CRN 015575
No Ethnic Origin
Avilacastillojr A M 23.01.22 01 1.00 CRN 015576
No Ethnic Origin
Aziz A M 31.12.86 2b 5.00 CRN 016104
Universal Credit
Bashar N F 29.12.94 01 1.00 23.80 CRN 016363
Battiato C F 25.10.94 2b 5.00 65.20 CRN 015702
Begum R F 07.09.59 2a 3.00 CRN 016359
Employment Support
No treatment to justify band claimed
Begum S F 01.01.90 01 1.00 CRN 016240
Universal Credit
Bhoyar R F 07.05.90 2b 5.00 CRN 014599
Bibi S F 09.11.60 01 1.00 23.80 CRN 015284
Address/Pcode missing
No Ethnic Origin
Bibi S F 08.08.82 01 1.00 CRN 015889
Universal Credit
No Ethnic Origin
Biney E M 11.06.17 2a 3.00 CRN 015294
No treatment to justify band claimed
Boadu C F 31.03.77 03 12.00 CRN 015561
Income Support
No treatment to justify band claimed
No Ethnic Origin
Bohan K F 18.03.15 01 1.00 CRN 015303

3
NATIONAL HEALTH SERVICE

Contract QMF 1017730000

Statement Reference 2223/12 NILESH PATEL

Performer 112881
Date 01/04/23 MRS ST TARIQ

Information only

FORMS PROCESSED (21/02/2023 - 22/03/2023)

Patient Sex DOB Band UDA/UOA Patients' Charge £ Comments
Bohan L F 06.10.13 2a 3.00 CRN 015304
Bohan S F 12.06.18 01 1.00 CRN 015301
Bohanowen R M 22.09.16 01 1.00 CRN 015300
Bojarek K F 02.08.85 01 1.00 23.80 CRN 015904
Bojarek K F 02.08.85 01 -1.00 -23.80 CRN 015904
Replaced as Requested
Bojarek K F 02.08.85 2a 3.00 65.20 CRN 015904
Schedule Query
Brennan E F 24.10.93 2a 3.00 65.20 CRN 015379
Brown K M 27.02.76 2b 5.00 65.20 CRN 015295
Bullock S M 12.08.82 2a 3.00 65.20 CRN 014860
No Ethnic Origin
Burke R F 03.07.17 2a 3.00 CRN 015613
No Ethnic Origin
Cabral B M 15.10.14 2b 5.00 CRN 015167
Incomplete Treatment
Calin A F 04.04.19 01 1.00 CRN 015397
Calin E F 09.09.19 01 1.00 CRN 015398
Carter D M 27.01.92 01 1.00 23.80 CRN 016014
Chandrasegaran D F 22.08.94 2b 5.00 CRN 015423
Choudhury A F 21.04.83 03 12.00 CRN 014852
Tax Credits
No treatment to justify band claimed
No Ethnic Origin
Colbourne T F 08.12.97 01 1.00 23.80 CRN 015970
No Ethnic Origin
Collins S M 21.07.59 2b -5.00 CRN 014610
Replaced as Requested
Universal Credit
Referral for AMS
Collins S M 21.07.59 2b 5.00 CRN 014610
Prescription Only Ignored
Universal Credit
Referral for AMS
Schedule Query
Dan M M 06.05.21 01 1.00 CRN 016410
Dong H M 19.09.22 01 1.00 CRN 015997
Dowlut F F 13.08.95 01 1.00 23.80 CRN 015794
Prescription Only Ignored
Dugdale W M 07.08.91 04 1.20 23.80 CRN 015978
Elliston C F 14.10.01 01 1.00 CRN 016048
Universal Credit
Elliston D F 19.03.05 2b 5.00 CRN 015731
Elliston J M 19.03.05 2a 3.00 CRN 015730
No treatment to justify band claimed

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NATIONAL HEALTH SERVICE

Contract QMF 1017730000

Statement Reference 2223/12 NILESH PATEL

Performer 112881
Date 01/04/23 MRS ST TARIQ

Information only

FORMS PROCESSED (21/02/2023 - 22/03/2023)

Patient Sex DOB Band UDA/UOA Patients' Charge £ Comments
Elliston S F 27.03.04 01 1.00 CRN 016047
Universal Credit
Ellistontaylor K M 25.07.20 01 1.00 CRN 016049
Erinoso A M 27.02.66 01 0.00 23.80 CRN 013808
Late submitted claim
Activity Units N/A
Fenn M M 22.04.51 2a 3.00 65.20 CRN 015722
No treatment to justify band claimed
No Ethnic Origin
Finogenov N M 09.07.08 2a 3.00 CRN 015307
No Ethnic Origin
Grainger G F 26.03.97 01 1.00 23.80 CRN 014776
Greenwood E F 09.01.75 01 1.00 23.80 CRN 015968
Prescription Only Ignored
Greenwood E F 09.01.75 01 -1.00 -23.80 CRN 015968
Replaced as Requested
Greenwood E F 09.01.75 01 1.00 23.80 CRN 015968
Prescription Only Ignored
Schedule Query
Hall M M 11.10.84 01 -1.00 -23.80 CRN 015012
Replaced as Requested
Hall M M 11.10.84 2b 5.00 65.20 CRN 015012
Address/Pcode missing
Schedule Query
Harshan S F 16.09.87 01 1.00 23.80 CRN 016529
No Ethnic Origin
Hughes T F 04.11.66 2b 5.00 65.20 CRN 013775
Prescription Only Ignored
Hussain Z F 02.03.21 01 1.00 CRN 015719
No Ethnic Origin
Iffat K F 11.02.11 01 1.00 CRN 015435
Inusa A F 26.08.94 2b 5.00 65.20 CRN 016312
Jacobs T F 27.03.61 01 -1.00 CRN 014769
Replaced as Requested
Universal Credit
Jacobs T F 27.03.61 01 -1.00 CRN 014769
Universal Credit
Replaced as Requested
Jacobs T F 27.03.61 01 1.00 CRN 014769
Universal Credit
Schedule Query
Jacobs T F 27.03.61 01 1.00 CRN 014769
Universal Credit
Schedule Query
Jaiswal A F 17.01.13 2a 3.00 CRN 015798
Jaiswal S F 22.12.15 01 1.00 CRN 015801
Jalocamara Y M 12.03.10 01 1.00 CRN 016030
Jannath A F 19.08.94 01 -1.00 CRN 014268
Replaced as Requested

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NATIONAL HEALTH SERVICE

Contract QMF 1017730000

Statement Reference 2223/12 NILESH PATEL

Performer 112881
Date 01/04/23 MRS ST TARIQ

Information only

FORMS PROCESSED (21/02/2023 - 22/03/2023)

Patient Sex DOB Band UDA/UOA Patients' Charge £ Comments
Universal Credit
Jannath A F 19.08.94 03 12.00 CRN 014268
Universal Credit
No treatment to justify band claimed
Schedule Query
Johnston I F 29.04.97 03 -12.00 CRN 014353
Universal Credit
Replaced as Requested
Johnston I F 29.04.97 03 12.00 CRN 014353
Prescription Only Ignored
Universal Credit
No treatment to justify band claimed
Johnston I F 29.04.97 03 12.00 CRN 014353
Prescription Only Ignored
Universal Credit
No treatment to justify band claimed
Schedule Query
Jukneviciuts D M 03.02.15 2a 3.00 CRN 016262
Kamali D M 22.07.20 01 1.00 CRN 016009
Kamali Z F 05.08.16 01 1.00 CRN 016008
No Ethnic Origin
Kamara A M 21.05.15 2a 3.00 CRN 015733
No treatment to justify band claimed
Kamara O M 27.04.09 01 1.00 CRN 015734
Kaur L F 30.10.70 01 1.00 CRN 015599
Job Seeker's Allowance
No Ethnic Origin
Khadja S F 06.01.77 2a 3.00 CRN 015853
Universal Credit
Khan J M 24.11.88 2a 3.00 65.20 CRN 015057
Khelifa E F 14.02.12 2a 3.00 CRN 015610
No Ethnic Origin
Khelifa Y F 04.10.07 2a 3.00 CRN 015606
No Ethnic Origin
Khong T F 22.09.95 01 1.00 23.80 CRN 015759
Kuczynska M F 21.07.88 01 1.00 23.80 CRN 015856
Kuzhivelil V F 06.10.87 01 1.00 23.80 CRN 016526
No Ethnic Origin
Kwong N M 14.01.82 01 1.00 23.80 CRN 016487
Lam W F 12.10.87 01 1.00 CRN 015718
Langar P M 08.12.92 01 1.00 23.80 CRN 016277
Lewis R M 27.09.09 01 1.00 CRN 015270
Lourdjane A F 01.05.16 01 1.00 CRN 016532
No Ethnic Origin
Lourdjane H F 05.12.19 01 1.00 CRN 016533
Magowan J M 17.02.94 2a 3.00 65.20 CRN 015693
Mahathir K M 20.02.07 01 1.00 CRN 015434

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NATIONAL HEALTH SERVICE

Contract QMF 1017730000

Statement Reference 2223/12 NILESH PATEL

Performer 112881
Date 01/04/23 MRS ST TARIQ

Information only

FORMS PROCESSED (21/02/2023 - 22/03/2023)

Patient Sex DOB Band UDA/UOA Patients' Charge £ Comments
Malikevans M M 25.03.88 01 1.00 23.80 CRN 015571
No Ethnic Origin
Marciniak K F 05.08.99 01 1.00 23.80 CRN 015777
Mason A M 06.08.93 03 12.00 282.80 CRN 015565
No treatment to justify band claimed
Mathys Y F 22.01.87 2a 3.00 CRN 016138
Meyer N F 27.11.95 01 1.00 23.80 CRN 015427
Miah A M 15.12.94 2a 3.00 65.20 CRN 015267
Miah M M 25.12.21 01 1.00 CRN 015299
Michalik L F 19.08.21 01 1.00 CRN 015861
No Ethnic Origin
Millar B F 12.10.95 2a 3.00 CRN 016320
Address/Pcode missing
Income Support
No Ethnic Origin
Motero I F 07.03.92 2a 3.00 65.20 CRN 015141
No treatment to justify band claimed
Nathan D F 16.12.64 03 12.00 282.80 CRN 015621
No treatment to justify band claimed
Obiriyaboah F F 06.04.65 01 1.00 23.80 CRN 015986
No Ethnic Origin
Ogbeifun O F 04.09.97 03 12.00 282.80 CRN 015770
No treatment to justify band claimed
Ohiri J M 05.06.79 01 1.00 23.80 CRN 015399
Orugboh L F 20.06.18 01 1.00 CRN 015264
Ozaner S M 14.10.76 01 1.00 23.80 CRN 015744
Perez D F 05.10.17 01 1.00 CRN 016010
Pir A M 20.09.91 01 1.00 23.80 CRN 016283
Qureshiyasin S M 08.03.19 01 1.00 CRN 015796
No Ethnic Origin
Radovanovic I M 11.08.74 01 1.00 23.80 CRN 016500
Prescription Only Ignored
Radovanovic K F 10.09.08 01 1.00 CRN 016260
Radovanovic L F 09.09.06 01 1.00 CRN 016258
Rahman K F 08.08.14 2a 3.00 CRN 016055
Rahman S F 16.04.81 03 12.00 CRN 014112
Universal Credit
No treatment to justify band claimed
Ramdin M M 18.02.19 01 1.00 CRN 016051
Ramdin R M 16.11.15 01 1.00 CRN 016052
No Ethnic Origin
Ramos G F 10.01.81 01 1.00 23.80 CRN 016325
No Ethnic Origin
Robinson G F 07.03.77 03 12.00 CRN 014525
Universal Credit
No treatment to justify band claimed

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NATIONAL HEALTH SERVICE

Contract QMF 1017730000

Statement Reference 2223/12 NILESH PATEL

Performer 112881
Date 01/04/23 MRS ST TARIQ

Information only

FORMS PROCESSED (21/02/2023 - 22/03/2023)

Patient Sex DOB Band UDA/UOA Patients' Charge £ Comments
Rosca A F 20.01.89 01 1.00 23.80 CRN 015704
Ruel D F 16.11.18 01 1.00 CRN 016129
No Ethnic Origin
Ruel J F 26.02.20 01 1.00 CRN 016131
Ruel R F 23.07.98 04 1.20 CRN 015308
Prescription Only Ignored
Universal Credit
Ruel R F 26.02.20 01 1.00 CRN 016127
No Ethnic Origin
Ruel S M 09.09.21 01 1.00 CRN 016130
No Ethnic Origin
Russell L M 10.01.52 2b 5.00 65.20 CRN 014771
Said A F 21.07.12 2a 3.00 CRN 016328
Said M F 25.09.17 01 1.00 CRN 016326
Said S F 22.06.09 2b 5.00 CRN 016327
No Ethnic Origin
Sammons J M 28.03.17 01 1.00 CRN 016479
Satomaran E M 06.03.11 01 1.00 CRN 015400
No Ethnic Origin
Satomaran L M 23.03.12 01 1.00 CRN 015401
No Ethnic Origin
Seed F M 03.01.80 01 1.00 CRN 016401
Universal Credit
Sheikhali R F 12.10.79 01 1.00 CRN 015431
Universal Credit
Siddiqui A M 19.10.13 2b 5.00 CRN 014736
Prescription Only Ignored
No Ethnic Origin
Slim S F 23.05.87 01 1.00 CRN 014013
Prescription Only Ignored
Smith M M 16.10.14 01 1.00 CRN 015405
Smith T M 15.08.16 2b 5.00 CRN 016319
Address/Pcode missing
Sowe M M 26.08.14 01 -1.00 CRN 014643
Replaced as Requested
Sowe M M 26.08.14 2a -3.00 CRN 014643
Replaced as Requested
Sowe M M 26.08.14 2a 3.00 CRN 014643
No treatment to justify band claimed
No Ethnic Origin
Schedule Query
Sowe M M 26.08.14 2a 3.00 CRN 014643
No treatment to justify band claimed
No Ethnic Origin
Schedule Query
Swift C F 29.10.84 01 1.00 CRN 015615
Universal Credit
No Ethnic Origin
Tasneem R F 19.02.15 2b 5.00 CRN 015171

8
NATIONAL HEALTH SERVICE

Contract QMF 1017730000

Statement Reference 2223/12 NILESH PATEL

Performer 112881
Date 01/04/23 MRS ST TARIQ

Information only

FORMS PROCESSED (21/02/2023 - 22/03/2023)

Patient Sex DOB Band UDA/UOA Patients' Charge £ Comments
Theophilou P M 06.01.51 03 12.00 CRN 014855
Prescription Only Ignored
HC2 Certificate
No treatment to justify band claimed
Vargleese R F 10.03.68 2b 5.00 CRN 015975
HC2 Certificate
Vishnu V F 08.04.20 01 1.00 CRN 016527
No Ethnic Origin
Vrabie L M 21.02.86 03 12.00 CRN 014005
Universal Credit
No treatment to justify band claimed
Wafa A M 01.05.06 01 1.00 CRN 016534
No Ethnic Origin
Wallace N M 23.03.95 01 1.00 23.80 CRN 015712
No Ethnic Origin
Wang X F 13.12.83 01 1.00 23.80 CRN 016257
Willmott J M 22.09.71 2a 3.00 CRN 015778
HC2 Certificate
Willoughby A F 09.06.84 2b 5.00 65.20 CRN 015008
Xue J M 07.07.93 01 1.00 23.80 CRN 016122
Yasmin T F 27.12.95 01 1.00 CRN 015046
No Ethnic Origin
Zito O M 06.11.94 01 1.00 23.80 CRN 015902

9
NATIONAL HEALTH SERVICE

Contract QMF 1017730000

Statement Reference 2223/12 NILESH PATEL

Performer 112881
Date 01/04/23 MRS ST TARIQ

Information only

PERFORMER ACTIVITY SUMMARY (CURRENT FINANCIAL YEAR)

UNITS OF DENTAL ACTIVITY INFORMATION
Band Forms Weighting No of Units
1 Child 42 1.00 42.00
1 Adult 38 1.00 38.00
2 (pre 25/11/22) Child 0 0.00 0.00
2 (pre 25/11/22) Adult 0 0.00 0.00
2(a) Child 13 3.00 39.00
2(a) Adult 15 3.00 45.00
2(b) Child 9 5.00 45.00
2(b) Adult 13 5.00 65.00
2(c) Child 0 0.00 0.00
2(c) Adult 0 0.00 0.00
3 Child 0 0.00 0.00
3 Adult 11 12.00 132.00
1* Child 0 0.00 0.00 * = Urgent Treatment
1* Adult 2 1.20 2.40
Advice Only 0 0.00 0.00
Triage 0 0.00 0.00
Reg11 Child 0 0.00 0.00
Reg11 Adult 0 0.00 0.00
Prescriptions Issued 0 0.00 0.00 Dom. Services 0
Denture Repairs 0 0.00 0.00 Sedation Services 0
Bridge Repairs 0 0.00 0.00 Further Treatment 0
Removal of Sutures 0 0.00 0.00 Incomplete Trmt 1
Arrest of Bleeding 0 0.00 0.00 Guaranteed Trmt 0

Late Submitted Forms 1

No of Deletions 11
General Units Total this Month 438.40 (excluding 1.00 submitted late)
Deletion Units -30.00
Net General Units 408.40

Orthodontic Treatment
Case Assessment Only 0 0.00 0.00 Ortho Abandoned 0
Assess and Accept 0 0.00 0.00 Ortho Discontinued 0
Appliance Fitted-Child<10 0 0.00 0.00 Ortho Completed 0
Appliance Fitted-Child>9 0 0.00 0.00
Appliance Fitted-Adult 0 0.00 0.00
Repairs to Appliances 0 0.00 0.00

No of Deletions 0 Ortho Reg 11 0

Ortho Units Total this Month 0.00
Deletion Units 0.00
Net Ortho Units 0.00
PATIENTS CHARGE TOTALS
Total Patient Charges £5,645.20
Remission Amount Total £2,956.80 Remission Cases 25
Exemption Amount Total (£2,701.00) Exemption Cases 70
Total to be deducted from contract value £2,688.40

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