Patient’s details	Date if claim sent electronically							

■	■	■	■

Surname

NHS
No.											

Mr	Mrs	Miss	Ms
Date of birth	First names

Previous surname/s

Home address			Temporary address, if applicable	

Postcode		Postcode	
Telephone number		Telephone number	
Details of treatment should be sent to
Doctor’s name and full address

 	To be completed by the doctor	

Emergency treatment
■	Minor surgical operation
■	Treatment of fracture
■	General anaesthetic
■	Reduction of dislocation
■	Other
■	Telephone advice only

■	Immediately necessary treatment
Temporary resident
Date of initial treatment

■	up to 15 days
■	over 15 days
■	Telephone advice only
■	Amended claim

Contraceptive services
■	non-IUD	■IUD
Number of night visits

Dental haemorrhage
■	Rate A	■Rate B
Number of vaccinations & immunisations
fee A	fee B

■	Rural practice payment. Distance in miles from patient’s temporary residence to my main surgery is

I declare to the best of my belief this information is correct and I claim the appropriate payment
as in the SFA. An audit trail is available at the practice for inspection by the HA’s authorised officers and auditors appointed by the Audit Commission.

Practice stamp

Authorised signature

Name	Date

Patient’s details	Date if claim sent electronically							

■	■	■	■

Surname

NHS
No.											

Mr	Mrs	Miss	Ms
Date of birth	First names

Previous surname/s

Home address			Temporary address, if applicable	

Postcode		Postcode	
Telephone number		Telephone number	
Details of treatment should be sent to
Doctor’s name and full address

 	Clinical records	

Do not write on this tinted area

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