I Would Be Grateful If You Would Supply the Following NRT Product*

Hertfordshire Health Improvement Service

01442 453071

Letter of Recommendation (voucher) to Supply Nicotine Replacement Therapy (NRT) 2017– 2018
*FOR SUPPLY BY COMMUNITY PHARMACY

Dear pharmacist,

I have discussed NRT with this client at our stop smoking servicetoday. In accordance with Hertfordshire Guidance: Stop Smoking Medication (2017)

I would be grateful if you would supply the following NRT product*:

Client’s name……………………………………………………………………………...... Quit Manager ID Number……………………………….

Address……………………………….………………………………………...... POST CODE……………………… D.O.B………………………

NOTE:ONLY NRT PATCHES CAN BE SUPPLIED AND CLIENT’S QUIT MANAGER ID MUST BE RECORDED

(Client may be advised to purchase a second NRT product or electronic cigarette if required)

Brand name / Strength
Please circle as appropriate / Pack size
Please circle as appropriate / Total Number of Packs
(two weeks maximum)
Nicorette / 25mg / 15mg / 10mg / 7 / 14 (25mg only)
Nicotinell / 21mg / 14mg / 7mg / 7
Niquitin / 21mg / 14mg / 7mg / 7 / 14 (21mg only)
Own brand patch
Please complete as appropriate

Client is required to pay one prescription charge per supply of NRT (e.g. two weeks’ supply of patches = one charge) unless the client is exempt.

Stop Smoking Advisor/Specialist’s name (Print)……………………………….... …………….. Signature……………...……………………………….

Location of service attended………………………….. ……………... …………. ……………… Date…………………………………………………….

This letter is valid for 7 days until………………………………………………………………….

An intermittent or second NRT product may only be supplied ifthe client is pregnant: YES ☐ NO☐

□

An intermittent product may only be supplied if the client has a serious reaction to patches (local skin reaction is normal): YES☐ NO☐

Client signature ………………………………………………………………………………………(Confirming the above)

If client has a diagnosed mental health condition,please contact HHIS for intensive support and treatment or advice.

HHIS contacted and approval obtained to supply a second NRT product YES ☐ NO☐

Manufacturer / Product name / Strength
Please circle as appropriate / Pack size
Please circle as appropriate / Number of packs
Nicorette / Gum / 2mg / 4mg / 6mg / 30 / 105 / 210
Mini Lozenge
(Cools) / 2mg / 4mg / 20 / 80
Inhalator / 15mg / 4 / 20 / 36
Quick Mist / 1mg / 1 / 2
Nasal Spray / 10ml / 1
Microtab / 2mg / 30 / 100
Nicotinell / Gum / 2mg / 4mg / 12 / 24 / 72 / 96 / 204
Lozenge / 1mg / 2mg / 36 / 96
Niquitin / Gum / 2mg / 4mg / 12 / 24 / 96
Mini Lozenge / 1.5mg / 4mg / 20 / 60
Lozenge / 2mg / 4mg / 36 / 72
Own brand product - please specify

Client Declaration of Exemption for Prescription Charges October 2017

Client must have been seen by a commissioned stop smoking service and set a quit date

To be completed by all patients receiving NRT products through the Letter of Recommendation(voucher) scheme.
Clients (or their representatives) who do not pay prescription charges must complete parts 1and 3. Those who pay a charge must complete parts 2 and 3.
If you are not sure about your entitlement to free prescriptions, pay and ask for an NHS receipt FP57 which tells you about how to get a refund.

Proof of exemption seen? Yes☐ No☐

Part 1 The client doesn’t have to pay because he/she:

A / Is under 16 years of age
B / Is 16, 17 or 18 and in full-time education
C / Is 60 years of age or over
D / Has a valid maternity exemption certificate
E / Has a medical exemption certificate
F / Has a prescription prepayment certificate
G / Has a War Pension exemption certificate
L / Is named on a current HC2 charges certificate
H / *Gets Income Support (IS)
K / *Gets income based Jobseeker’s Allowance (JSA ((IB))
M / *Is entitled to, or named on, a valid NHS Tax Credit Exemption Certificate
S / *Has a partner who gets Pension Credit Guarantee Credit (PCGC)

*Print the name of the person (either you or your partner) who gets IS, JSA (IB), PCGC or Tax Credit

Name: / Date of Birth: / NI number:
Declaration
For clients who do not have to pay / I declare that the information I have given on this form is correct and complete. I understand that if it is not, appropriate action may be taken. I confirm proper entitlement to exemption. To enable the NHS to check that I have a valid exemption and to prevent and detect fraud and incorrectness I consent to disclosure of relevant information from this form to and by the Prescription Pricing Authority, the NHS Counter Fraud and Security Management Service, the Department for Work and Pensions and Local Authorities.

Part 2 I have paid Now sign and complete Part 3 & 4

Part 3 I am the client ☐ I am the client’s representative☐

Part 4 Please sign and fill in below

Signature:------Date ------

Name (Print):------

Address:------Postcode ------

For Pharmacy use only: Please recommend pre-payment certificate to prescription paying clients.
Only original forms should be accepted and retained for 7 years for audit purposes.You may claim £2.00 supply fee per transaction (i.e. 2 weeks supply = £2.00 fee) provided you complete an NRT invoice and summary sheet and return it to Hertfordshire Health Improvement Service.
Dispensed by/Pharmacy Stamp & Date / NRT Supplied
NRT Not Supplied
Reason ………………………………………………
Hertfordshire Health Improvement Service - Hertfordshire County Council,
Apsley Campus 1, Brindley Way, Hemel Hempstead, Hertfordshire, HP3 9BF.
Telephone (for clients) 0800 389 3 998 (for professionals) 01442 453071 Fax 01442 453070

* For review April 2018For review April 2018FF