Family Doctor Services Registration - Nhs Form (Page 2 of 2) in pdf

Family doctor services registration

GMS1

To be completed by the doctor

Doctors Name

HA Code

I have accepted this patient for general medical services

For the provision of contraceptive services

I have accepted this patient for general medical services on behalf of the doctor named below who is a member of this practice

Doctors Name, if different from above

HA Code

I am on the HA CHS list and will provide Child Health Surveillance to this patient or

I have accepted this patient on behalf of the doctor named below, who is a member of this practice and is on the

HA CHS list and will provide Child Health Surveillance to this patient.

Doctors Name, if different from above

HA Code

I will dispense medicines/appliances to this patient subject to Health Authority’s Approval

I am claiming rural practice payment for this patient.

Distance in miles between my patient’s home address and my main surgery is

I declare to the best of my belief this information is correct and I claim the

Practice Stamp

appropriate payment as set out in the Statement of Fees and Allowances. An audit

trail is available at the practice for inspection by the HA’s authorised officers and

auditors appointed by the Audit Commission.

Authorised Signature

Name

Date _______/_______/_______

SUPPLEMENTARY QUESTIONS

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being

ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals

of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to

all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant

patient leaflet, available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise

you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any

immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including

with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost

recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please tick one of the following boxes:

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for

example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can

provide documents to support this when requested

I do not know my chargeable status

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate

action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

Signed:

Date:

DD MM YY

Print name:

Relationship to

patient:

On behalf of:

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in

the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC)

DETAILS and S1 FORMS

If yes, please enter details from your EHIC or

Do you have a non-UK EHIC or PRC?

YES:

NO:

PRC below:

Country Code:

3: Name

4: Given Names

5: Date of Birth

DD MM YYYY

6: Personal Identification

Number

If you are visiting from another EEA

country and do not hold a current

7: Identification number

EHIC (or Provisional Replacement

of the institution

Certificate (PRC))/S1, you may be billed

8: Identification number

for the cost of any treatment received

of the card

outside of the GP practice, including

at a hospital.

9: Expiry Date

DD MM YYYY

PRC validity period

(a) From:

DD MM YYYY

(b) To:

DD MM YYYY

Please tick

if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for

work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data

and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of

cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of

recovering your NHS costs from your home country.

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Family Doctor Services Registration - Nhs Form Page 2

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