CONFIDENTIAL

REQUEST FOR REIMBURSEMENT FOR THE UNUSED ELEMENT OF A PRESCRIPTION PRE-PAYMENT CERTIFICATE IN RELATION TO THE CESSATION OF GLUTEN FREE FOOD PRESCRIBING

Claimant / patient’s full name
Home address
Name of GP practice
Name of representative (if applicable)
Contact telephone number
DECLARATION AND CONSENT IN RESPECT OF THE PATIENT: / Tick to confirm
I enclose:
  1. Proof of payment for the pre-payment certificate
  2. The pre-payment certificate (card)

The pre-payment certificate was for a duration of __ months and became effective on dd / mm / yyyy.
Due to its cancellation, the last date of it being effective was dd / mm / yyyy.
I have paid:
  1. £ ___ in full for the certificate,
OR
  1. £ per month by direct debit commencing dd / mm / yyyy_and finishing dd / mm /yyyy
and £ to the NHSBSA for payment of any outstanding balance of the certificate following direct debit cancellation (proof of payment required).
  • I declare that I have been diagnosed with Coeliac disease.
  • I declare that I will no longer claim exemption from prescription charges on the basis of having a prescription prepayment certificate, unless I purchase another prescription prepayment certificate from NHS-BSA.
  • I declare that the information given on this form is correct and complete and I understand that if I knowingly provide false information I may be liable to prosecution and/or civil proceedings.
  • I consent to the disclosure of relevant information on this form to and by the Harrogate and Rural District Clinical Commissioning Groupfor the purpose of verification.
  • I consent to the disclosure of information on this form to the Counter Fraud and Security Management Service, a division of the NHS Business Services Authority, for the purpose of prevention, detection, investigation and prosecution of fraud and any other unlawful activity affecting the NHS.

Signature of claimant / patient: ______Date ______
Please send completed forms and relevant documentation to:
Finance Team
Harrogate and Rural District Clinical Commissioning Group
1 Grimbald Crag Court
St James Business Park
Knaresborough
HG5 8QB

FURTHER INFORMATION

  • Refunds for pre-payment certificates will be dealt with on an individual basis.
  • Refunds will only be considered for certificates purchased before 11 August 2016. The CCG position on the prescribing of gluten free products became effective on 1 November 2016, therefore prescription prepayment certificates purchased up until 10 August 2016 would have been effective for prescriptions dispensed during July to October.
  • The claim requires the submission of the prescription prepayment certificate plus proof of the original purchase of the certificate and for any additional payments made to NHS-BSA regarding cancellation of direct debit.
  • Refunds will be pro-rata (based on remaining full months) and calculated as:

Three-month PPC / Twelve-month PPC
No Refund / During months 4 to 11 – proportional refund
During month 12 – no refund
  • Claims for refunds for prescription prepayment certificates will be considered until 31 March 2017 only.

Contact us

For more information, please contact the CCG:

Harrogate and Rural District Clinical Commissioning Group

1 Grimbald Crag Court

St James Business Park

Knaresborough

HG5 8QB

Tel: 01423 799300

Email:

Confidentiality

The information you have provided is kept strictly confidential by NHS Harrogate and Rural District Clinical Commissioning Groupin accordance with the Data Protection Act. Your personal information will not be shared with any other agencies apart from NHS Business Services Authority.

Prescription prepayment certificate – cancellation claim formFinal 1.0 2016/17