Declaration of the GP Applying for Payment I declare that: The information I have given on this form is correct & complete and I understand that if it is not action may be taken against me. For the purposes of verification of this application I consent to the disclosure of relevant information. The performer is eligible for sickness leave either under statute, a partnership agreement or other agreement between the partners of a partnership, or a contract of employment that entitles the performer on leave to be paid their full salary by the contractor during their leave of absence The practice is not claiming another payment for locum cover in respect of the absence From 1st April 2015 improved arrangements have been agreed, to cover both external locums/GPs and cover provided by existing GPs within the practice who do not already work full time The practice will undertake to inform NHS England of any change in the Sickness deputising arrangements without delay The performer on leave will not engage in conduct that is prejudicial to their recovery. The performer on leave will not perform any clinical services of another person, unless under the medical direction and with approval from NHS England. The contractor will summit claims for costs, including supporting evidence demonstrating the actual cost to it of the locum or existing GP cover, after they have been incurred and as soon as possible after the end of the month during which the costs were incurred. The contractor will be reimbursed for whichever is the lower the invoiced costs or the maximum claimable amount. NHS England will make payment as soon as – possible following receipt of claims The performer is intending to resume practice as a GP at the practice detailed above, provided that they are fit, when their period of absence is completed. I hereby apply for reimbursement under the current General Medical Services regulations and specifically Part 4 Section 15 of the current GMS Statement of Financial Entitlements Name: Date: Position held at practice: By printing my name, I certify and confirm that the information above is correct. Provision of false information may result in the matter being referred to the NHS Counter Fraud Service for investigation. Practices may also be liable for prosecution and civil recovery proceedings. This information may be disclosed by NHS England to the NHS Counter Fraud and Security Management Service for the purpose of verification of this claim and the investigation, prevention, detection and prosecution of fraud. Please complete this form and return to
Declaration of the GP Applying for Payment I declare that: The information I have given on this form is correct & complete and I understand that if it is not action may be taken against me. For the purposes of verification of this application I consent to the disclosure of relevant information. The performer is eligible for sickness leave either under statute, a partnership agreement or other agreement between the partners of a partnership, or a contract of employment that entitles the performer on leave to be paid their full salary by the contractor during their leave of absence The practice is not claiming another payment for locum cover in respect of the absence From 1st April 2015 improved arrangements have been agreed, to cover both external locums/GPs and cover provided by existing GPs within the practice who do not already work full time The practice will undertake to inform NHS England of any change in the Sickness deputising arrangements without delay The performer on leave will not engage in conduct that is prejudicial to their recovery. The performer on leave will not perform any clinical services of another person, unless under the medical direction and with approval from NHS England. The contractor will summit claims for costs, including supporting evidence demonstrating the actual cost to it of the locum or existing GP cover, after they have been incurred and as soon as possible after the end of the month during which the costs were incurred. The contractor will be reimbursed for whichever is the lower – the invoiced costs or the maximum claimable amount. NHS England will make payment as soon as possible following receipt of claims The performer is intending to resume practice as a GP at the practice detailed above, provided that they are fit, when their period of absence is completed. I hereby apply for reimbursement under the current General Medical Services regulations and specifically Part 4 Section 15 of the current GMS Statement of Financial Entitlements Name: Date: Position held at practice: By printing my name, I certify and confirm that the information above is correct. Provision of false information may result in the matter being referred to the NHS Counter Fraud Service for investigation. Practices may also be liable for prosecution and civil recovery proceedings. This information may be disclosed by NHS England to the NHS Counter Fraud and Security Management Service for the purpose of verification of this claim and the investigation, prevention, detection and prosecution of fraud. Please complete this form and return to