Ref: CRSDF01 Declaration Form: Service Provision in relation to Chemical Reagents Company Stamp To: Drug Tariff Team (or if a head office, attach a signed letterhead as authorisation) NHSBSA NHS Prescription Services Ground Floor Stella House Goldcrest Way Newburn Riverside Newcastle upon Tyne NE15 8NY Manufacturer Details Manufacturer Name Address Postcode Manufacturer Declaration I declare that the services listed below which are provided by in relation to the chemical reagents we manufacture and which are listed under Part IX of the Drug Tariff will continue to be provided for the period to 31 March 2015. Services Provided: Completed by: Telephone number: (authorised (in case of queries) signature) Name: Position: (please print name) Date:
Ref: CRSDF01 Declaration Form: Service Provision in relation to Chemical Reagents To: Drug Tariff Team NHSBSA NHS Prescription Services Ground Floor Stella House Goldcrest Way Newburn Riverside Newcastle upon Tyne NE15 8NY Company Stamp (or if a head office, attach a signed letterhead as authorisation) Manufacturer Details Manufacturer Name Address Postcode Manufacturer Declaration I declare that the services listed below which are provided by in relation to the chemical reagents we manufacture and which are listed under Part IX of the Drug Tariff will continue to be provided for the period to 31 March 2015. Services Provided: Completed by: (authorised signature) Telephone number: (in case of queries) Name: (please print name) Position: Date:
DT1B_IV_Diagnostics_Medical_Devices_Directive.docx