Tri-Health Contract CLAIM FORM IUCD’s & IUS Date Fitting Fitting non-reg All prep work Removal Reg patient which includes patient which completed that was NHS Number Fitting. 6 week check and includes Fitting. 6 fitting not NOT fitted Name of please removal week check and appropriate by the Individual give details removal (non reg practice performed and see fee patients only) procedure schedule 1 2 3 4 5 6 7 8 9 10 I declare to the best of my belief that this information is correct and Authorised signature I the appropriate payment as set out in the Tri-Health SLA. An Audit trail is available at the practice for inspection as necessary. Name: Date: PLEASE RETURN FORM TO: Liane Leak, Assistant Business Manager, Tri-Health, Doncaster Royal Infirmary, Armthorpe Road Doncaster DN2 5LT
Tri-Health Contract CLAIM FORM IUCD’s & IUS Date NHS Number Fitting Reg patient which includes Fitting. 6 week check and removal Fitting non-reg patient which includes Fitting. 6 week check and removal All prep work completed fitting not appropriate (non reg patients only) Removal that was NOT fitted by the practice Name of Individual performed procedure please give details and see fee schedule 1 2 3 4 5 6 7 8 9 10 I declare to the best of my belief that this information is correct and Authorised signature I the appropriate payment as set out in the Tri-Health SLA. An Audit trail is available at the practice for inspection as necessary. Name: Date: PLEASE RETURN FORM TO: Liane Leak, Assistant Business Manager, Tri-Health, Doncaster Royal Infirmary, Armthorpe Road Doncaster DN2 5LT
Tri%20Health%20IUCD%20SLA%20-%20Final%20Version.docx