EHC Service EHC3 Monthly Claim Form Form Pharmacy name: OCS code: Pharmacy address: Postcode: Claim for month of: Sheet … of … Pharmacy Reference V reason: advice (Please initials crossreference give each claim competence cycle? supplied listed here to medication; in the EHC1 hours hours hours hours proforma by Chlamydia 2 Fraser years packs <48 <72 <96 entering the supplied pharmacist postcode only) years supply 16 24: pharmacy of inducing within made anonymous supply – – patient reference code 13 years: of part of allocated to the 13 15 hours hours, hours, hours, tablet enzyme supply.) <16 >1 = vomited Date Number Age Under Age Age Supplying Patient Previous Supply checked <24 >24 >48 >72 E = (first If If E121105A XX 5/11/12 2 BA22 16 E Example 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Totals columns where indicated: = Total consultations £11.00 (A) = Total packs Levonelle® (POM pack) supplied £5.20 (B) = Total number of under-13’s supplied £5.00 (C) = Total number of 13 to supplied £2.00 (D) 16’s = Total number of 15-24’s advice £1.00 (E) given chlamydia = Total number supplied >72hours, <96hours £2.00 (F) Total amount claimed = (A)+(B)+(C)+(D)+(E)+(F)
Form EHC3 EHC Service Monthly Claim Form Pharmacy name: OCS code: Pharmacy address: Postcode: Claim for month of: Sheet … of … Pharmacy Reference (Please crossreference each claim listed here to the EHC1 proforma by entering the pharmacy reference code allocated to the supply.) Supplying pharmacist initials Date of supply Supply made Number of packs supplied Patient anonymous postcode (first part only) Age of patient If <16 years: Fraser competence checked Under 13 years Age 13 – 16 years Age 15 – 24: Chlamydia advice <24 hours >24 hours, <48 hours >48 hours, <72 hours >72 hours, <96 hours Previous supply in cycle? If >1 tablet supplied give reason: E = enzyme inducing medication; V = vomited within 2 hours Example E121105A XX 5/11/12 2 BA22 16 E 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Totals columns where indicated: Total consultations £11.00 = (A) Total packs Levonelle® (POM pack) supplied £5.20 = (B) Total number of under-13’s supplied £5.00 = (C) Total number of 13 to 16’s supplied £2.00 = (D) Total number of 15-24’s given chlamydia advice £1.00 = (E) Total number supplied >72hours, <96hours £2.00 = (F) Total amount claimed (A)+(B)+(C)+(D)+(E)+(F) =