Deregistration / Application Cancellation Form

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We are sorry to hear that you would like to deregister/cancel your application with the HPAC.

Thank you for your support to date and we wish you the very best for the future. Regarding deregistration, in order to securely process your request, we require you to complete this form in full.

Please ensure you have read the notice below before completing this form.

Deregistration while under investigation or with any active conditions on your registration:

In line with the terms and conditions of registration with us, deregistration will not prevent an investigation from going ahead, nor will it remove you from the register if you have any unspent cautions or suspension orders. Please note if HPAC receives credible evidence of misconduct, criminal behaviour or unsafe practice covered by the HPAC code of conduct regarding yourself as a clinician during your time on the register, you will still be subject to a full investigation by the fitness to practice panel. If the outcome of such an investigation is for a concern, suspension order or *struck-off notice to be put in place, your profile will be re-listed for public safety with the order in place.

Your HPAC ID card must be destroyed, you will be required to supply a face-up image of your HPAC ID card cut into four pieces.

Changing your mind:

If you change your mind and/or wish to discuss things further you can call us on 0208 004 8226 or email us at: communications@hpac-uk.org and we would be happy to help.

Once processed you may *re-apply to the HPAC register after 12 months have passed since your de-registration date.

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*Struck-off notices remain in place in perpetuity.

*If you are de-registering during an investigation you may not re-apply for five years.
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We need to confirm your details to ensure you are the account holder
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HPAC Registration Number* This field is required.If you have not been issued one, please enter n/a
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Email* This field is required.
example@example.com
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Name* This field is required.
First Name
Last Name
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Address* This field is required.
Street Address
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Your date of birth* This field is required.
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We require you to destroy your ID card* This field is required.NB: If you no longer have your HPAC ID card, per the terms and conditions of registration a £30 fee will be applied
Take a picture/upload an image of my HPAC ID card cut into four pieces.
I have lost my card and will pay the £30 fee
I never received an HPAC ID card
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Please upload images of your HPAC ID card cut into four pieces* This field is required.All the ID card fragments must be in the same photo, face up, clearly visible and in focus.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Are you under any investigation, criminal, civil or in connection with your duties as a clinician or otherwise?If yes please ensure you declare these reasons under "reason for cancellation"
YESNO
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Reason for deregistration* This field is required.NB: You must declare in reasons relating to investigation, criminal, civil or in connection with your duties as a clinician.
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Please sign the following declaration stating that you are not under any form of investigation:* This field is required.I declare that to the best of my knowledge I am not under any investigation, criminal, civil or in connection with my duties as a clinician and that the reasons for deregistration are unrelated to any such concerns.
ClearThis field manditory
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Were you given a cancellation code by HPAC
YESNO
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Please enter code
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I understand that upon submission of this form, subject to any current restrictions on my profile, I will be removed from the HPAC register, and I may not refer to myself as HPAC registered or use HPAC's logo. No refund is due if this cancellation has occurred after 14 days of my registration date or annual renewal inception date. If I pay via a monthly payment plan for the year, any outstanding balance for the remainder of the year will be immediately due. If I cancel within 14 days of my application/registration/renewal date, I will receive a full refund, less the two following costs, as applicable: (1) if HPAC has commenced or completed a DBS check for me, I will be charged £45. (2) if my ID card has already been ordered, I will be charged £30. If I am paying via a monthly credit plan for the year, fees for items (1) and (2) will be immediately due (as applicable). I accept that deregistration will not prevent an investigation from going ahead, nor will it remove me from the register if you have any unspent cautions or suspension orders. If the HPAC receives credible evidence of misconduct, criminal behaviour or unsafe practice covered by the HPAC code of conduct regarding myself as a clinician during my active time on the register, I will still be subject to a full investigation by the fitness to practice panel. If the outcome of such an investigation is for a concern, suspension order or *struck-off notice to be put in place, my profile will be re-listed for public safety with the restriction order in place. I understand that I can only *re-apply twelve months from my date of deregistration.* This field is required.*You must have uploaded evidence of your ID card's destruction per the guidelines in this form *Struck-off notices remain in place in perpetuity. *If you are de-registering during an investigation you may not re-apply for five years.
Tick to confirm
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I understand that upon submission of this form, subject to any current restrictions on my profile, I will be delisted from the HPAC register, and I may not refer to myself as HPAC registered or use HPAC's logo. No refund is due if this cancellation has occurred after 14 days of my registration date or annual renewal inception date. If I cancel within 14 days of my application/registration/renewal date, I will receive a full refund, less the two following costs, if applicable: (1) if HPAC has commenced or completed a DBS check for me, I will be charged £45. (2) if my ID card has already been ordered, I will be charged £30. I accept that deregistration will not prevent an investigation from going ahead, nor will it remove me from the register if you have any unspent cautions or suspension orders. If the HPAC receives credible evidence of misconduct, criminal behaviour or unsafe practice covered by the HPAC code of conduct regarding myself as a clinician during my active time on the register, I will still be subject to a full investigation by the fitness to practice panel. If the outcome of such an investigation is for a concern, suspension order or *struck-off notice to be put in place, my profile will be re-listed for public safety with the restriction order in place. I understand that I can only *re-apply twelve months from my date of deregistration.* This field is required.*You must have uploaded evidence of your ID card's destruction per the guidelines in this form *Struck-off notices remain in place in perpetuity. *If you are de-registering during an investigation you may not re-apply for five years.
Tick to confirm
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Please sign the following declaration stating that you have disclosed all relevant details relating to your reason for cancellation:* This field is required.I declare that to the best of my knowledge I have declared all relevant details in relation to any investigation, criminal, civil or in connection with my duties as a clinician. I am aware that any such concerns may be recorded on my record as a registrant for a minimum of 3 years by HPAC and subject to review by the concerns committee I may receive a caution, suspension or struck-off notification against my HPAC public profile for the 36 month period before my right to be forgotten can be applied.
ClearThis field manditory
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