Performer List Change Notification

Notes for Completion

All performers are required to notify NHS England of any changes to the details recorded on the National Performer Lists. This includes any change of registered address, practice or the status of inclusion in the list.

Medical Performers should complete Section 1 only

Dental Performers should complete Section 2 only

Ophthalmic Performers should complete Section 3 only

When complete, forms should be returned to

Performer List Applications

Wessex Area Team

PPSA
Coitbury House
Friarsgate
Winchester
Hampshire
SO23 8EE

01962 876651

Medical and Dental Performers providing services for the first time following traineeship should also provide their Certificate of Completion of Training/Vocational Training Certificate together with a letter of clinical reference from their trainer.

If you are not staying in Wessex after qualification (CCT)

More information and contact details of other Local Area Teams can be found at the National Performers List website

http://www.performer.england.nhs.uk/AT/SearchByPostcode


Section 1

Medical Performer List Change of Practice or Transfer of Status Application

Name:
/ GMC Number:
Home Address
Post Code
Contact Tel No

1.a In relation to your current registration on the Performer List for GP’s who are attached to a practice, please indicate your current practice details:-

Practice Code
Practice address:
NHS Area Team:

1.b If you are not attached to a practice, please provide:-

GMC Registered Address:
Locality in which you have been working
NHS Area Team:

For notification of resignation or retirement from the National Performer List, please go directly to Question 4

2. If you are remaining on the National Performer List, please indicate in what capacity you are currently included and your requested status:-

(Please tick as appropriate) / Current / New / Please provide details of the practice you are joining
Principal Doctor (partner) / Practice Code
Practice Address
NHS Area Team
Salaried Doctor
Trainee GP
Retainer
Returner
Locum
Please provide your DI Number for prescriptions if one has been issued
Effective Date of Change

3. If you are providing services as a locum, please confirm your new GMC registered address and the area in which you will provide services:-

GMC Registered Address:
Locality in which you will provide services
NHS Area Team:

Declaration

In accordance with Regulation 9 of the Performer List Regulation 2013, I confirm that there are no circumstances that effect my entitlement to be included on the Medical Performers list.

Signed: Date:

4. If you wish your name to be removed from the National Performer List, please complete the following:

Reason for removal
(Delete as appropriate) / Resignation/ Retirement
Do you wish to apply for NHS Pension Scheme Retirement Benefits / Yes/No
What is your last day of NHS Service
Please confirm your contact details for future correspondence:
Address
Postcode
Tel No
Email

Signed: Date: