A Completed Copy of This Form Should Be Submitted by the Pharmacy Contractor to Their Local

A completed copy of this form should be submitted by the pharmacy contractor to their local NHS England team prior to provision of the Medicines Use Review and Prescription Intervention service. The local NHS England team does not need to acknowledge receipt of the form prior to the pharmacy commencing provision of the service.

Pharmacy details
Name of pharmacy contractor:
ODS code (F code):
Pharmacy address:
Address for correspondence (if different from above):
Eligibility to provide the service
1. / I / we confirm that the pharmacy is complying with the Terms of Service relating to the provision of Essential Services, and has an acceptable system of clinical governance.
2. / I / we confirm that the pharmacy premises contain a consultation area which meets the following requirements:
i.  The consultation area is clearly designated as an area for confidential consultations;
ii.  The consultation area is distinct from the general public areas of the pharmacy; and
iii.  The consultation area is an area where both the patient and pharmacist can sit down together and are able to talk at normal speaking volumes without being overheard by other visitors to the pharmacy, or by pharmacy staff undertaking their normal duties.
3. / I enclose a copy of an MUR certificate for each pharmacist who will be providing Advanced Services from the above premises; OR
A copy of an MUR certificate for each pharmacist who will be providing Advanced Services from the above premises has previously been sent to the local NHS England team.
‘MUR certificate’ means a certificate awarded or endorsed by a higher education institute being evidence that a pharmacist has satisfactorily completed an assessment relating to the competency framework for pharmacists providing Advanced Services approved by the Secretary of State. The document ‘Competency Framework for the Assessment of Pharmacists Providing the Medicines Use Review (MUR) and Prescription Intervention Service’ dated 23rd December 2004 is published by the Department of Health and is available on the PSNC website http://dld.bz/ee4u3
Pharmacy contractor’s declaration
4. / I / we undertake to provide the Medicines Use Review & Prescription Intervention Service from the above premises from (date).
Signed: / Date
Contact name for queries relating to this form: / Telephone
number