PROVISION OF EMERGENCY HORMONAL CONTRACEPTION SCHEME Claim for month of ………………………………… 201 … budget code 2050 7104 Consultation Consultation Levonelle Ellaone Reason for Ethnicity Patients Full Patients Accredited Total Claim Date Fee (£10.00) 1500 Supplied Pregnancy (enter code) postcode date of Birth Pharmacist per patient Supplied (£17.00) Test (£6.00) ( enter code) Please note: Total Claim Claims run from the 1st day of each month to the last day of the month. Claims must be made within 7 working days of the month end to ensure payment within the following month Please ensure you complete another form if more than 10 patients receive treatment I certify the above claims are legitimate and are in accordance with the PGD’s Name of Pharmacy: …………………………………………………….. Pharmacists Name: …………………………………………………….. Signature: ……………………………………………………….. Date: ……………………………
PROVISION OF EMERGENCY HORMONAL CONTRACEPTION SCHEME Claim for month of ………………………………… 201 … budget code 2050 7104 Consultation Date Consultation Fee (£10.00) Levonelle 1500 Supplied (£6.00) Ellaone Supplied (£17.00) Reason for Pregnancy Test ( enter code) Ethnicity (enter code) Patients Full postcode Patients date of Birth Accredited Pharmacist Total Claim per patient Total Claim Please note: Claims run from the 1st day of each month to the last day of the month. Claims must be made within 7 working days of the month end to ensure payment within the following month Please ensure you complete another form if more than 10 patients receive treatment I certify the above claims are legitimate and are in accordance with the PGD’s Name of Pharmacy: …………………………………………………….. Pharmacists Name: …………………………………………………….. Signature: ……………………………………………………….. Date: ……………………………
02-Claim-for-Emergency-Hormonal-Contraception-.docx