…………………………………………………………………… Details of GP performer taking leave First Name: Surname: ………………………………………. ……………………………. Claim period: Number of ………………………………….. weeks: …………………….. Number of clinical sessions worked……………………………. Reason for claim (delete as appropriate): MATERNITY / PATERNITY / ADOPTION / SICKNESS Declaration of GP performer taking leave that: I ………………………………………………………………………………….. certify (Full name in capitals) The information shown on the reverse side of this form provides an explanation of how the practice intends to cover my period of absence.
Details of GP performer taking leave Surname: ………………………………………. First Name: ……………………………. Claim period: ………………………………….. Number of weeks: …………………….. Number of clinical sessions worked……………………………. Reason for claim (delete as appropriate): MATERNITY / PATERNITY / ADOPTION / SICKNESS Declaration of GP performer taking leave I ………………………………………………………………………………….. certify that: (Full name in capitals) The information shown on the reverse side of this form provides an explanation of how the practice intends to cover my period of absence. ……………………………………………………………………
Primary-Medical-Care-Policy-Guidance.docx