APPLICATION FOR ADDITIONAL PAYMENTS DURING SICKNESS LEAVE Please complete this form and return to (Original form to be completed and returned, scanned copies will not be accepted) Please provide evidence or supporting documentation where appropriate, such as a Medical certificate in respect of the absence. (Updated certificates for Long term sickness must be submitted with claim forms) Notes: This claim is made in line with the current GMS Statement of Financial Entitlements 2013, Part 4 (Payments For Specific Purposes), Section 15 (Amended April 2018) The maximum claimable (after more than 2 weeks absent) is £1,751.52 (a) 26 Weeks for the full amount of the sum NHS England has determined (b) A further 26 weeks for half the full amount of the sum NHS England initially determined Any amounts payable by way of reimbursement: (a) Are not to be paid on a pro-rata basis having regard to the absent performer’s working pattern (b) Whichever is the lower - the invoiced costs or the maximum claimable amount Ensure the practice have made arrangements to engage a GP or GP locum Sickness leave can now be covered by both external locums/GPs and of cover provided by existing GPs within the Practice who do not already work full time TYPE OF APPLICATION - DETAILS OF GP ON LEAVE- Surname: First name: Status in Practice: GMC Number: Practice name: Practice code: GMS/PMS/APMS: First day away from practice because of Sickness: Date claim starts (after first 2 weeks of Sickness): Date of return to work (If Known): Declaration of the GP Applying for Payment
APPLICATION FOR ADDITIONAL PAYMENTS DURING SICKNESS LEAVE Please complete this form and return to (Original form to be completed and returned, scanned copies will not be accepted) Please provide evidence or supporting documentation where appropriate, such as a Medical certificate in respect of the absence. (Updated certificates for Long term sickness must be submitted with claim forms) Notes: This claim is made in line with the current GMS Statement of Financial Entitlements 2013, Part 4 (Payments For Specific Purposes), Section 15 (Amended April 2018) The maximum claimable (after more than 2 weeks absent) is £1,751.52 (a) 26 Weeks for the full amount of the sum NHS England has determined (b) A further 26 weeks for half the full amount of the sum NHS England initially determined Any amounts payable by way of reimbursement: (a) Are not to be paid on a pro-rata basis having regard to the absent performer’s working pattern (b) Whichever is the lower - the invoiced costs or the maximum claimable amount Ensure the practice have made arrangements to engage a GP or GP locum Sickness leave can now be covered by both external locums/GPs and of cover provided by existing GPs within the Practice who do not already work full time TYPE OF APPLICATION - DETAILS OF GP ON LEAVE- Surname: First name: Status in Practice: GMC Number: Practice name: Practice code: GMS/PMS/APMS: First day away from practice because of Sickness: Date claim starts (after first 2 weeks of Sickness): Date of return to work (If Known): Declaration of the GP Applying for Payment
sa1-2018.docx