For practice use only Patient NHS number Patients Name: Identity verified by Date Method 2 forms of ID required for each – (initials) application including photo ID. Vouching Vouching with information in record Passport Driving Licence Bank Statement Utility Bill Birth Certificate Marriage Certificate Other* *please specify other: Authorised by Date Date account created Date passphrase sent
For practice use only Patient NHS number Patients Name: Identity verified by (initials) Date Method – 2 forms of ID required for each application including photo ID. Vouching Vouching with information in record Passport Driving Licence Bank Statement Utility Bill Birth Certificate Marriage Certificate Other* *please specify other: Authorised by Date Date account created Date passphrase sent
6%20APPLICATION%20TO%20REQUEST%20ON%20LINE%20ACCESS.docx