Home Forms
Here you can find a selection of commonly requested forms which you may find useful.
Alphabetical List of Charges, Special Container and Calendar Pack List
These lists can be found in Dispensing resources which can be downloaded here.
Appliance Services template forms (introduced 1 April)
These templates can be found in the Appliance Services section of the website or by clicking here.
Bank Holiday Hours Notification form
The form for notifying a PCT of intended bank holiday opening hours can be downloaded here.
Community Pharmacy Patient Questionnaire.
The forms for conducting the community pharmacy patient questionnaire aswell as a template letter for the submission of findings from the questionnaire to the PCT can be downloaded here.
Complaints Forms.
A range of model forms and documents to support responding to complaints can be downloaded here.
DDA Toolkit.
NHS Primary Care Contracting have published a Disability Discrimination Act Resource Toolkit which can be used to assess patients for auxiliary aids, which can be found here.
ETP Monthly Allowance Claim Form.
The form for claiming the ongoing ETP Allowance can be downloaded from the PSNC Website ,along with a template letter that contractor’s can use to inform a PCT if they become unable to operate the Electronic Prescription Service. They can be found here.
ETP Release 1 Allowance Claim Form
The form for claiming the Release 1 Allowance, for pharmacies which were established after December 2005 and missed out on receiving one or both of the £1300 Release 1 deployment allowances, can be downloaded here.
Fitness to Practise (FTP).
The form for contractors to notify their PCT of convictions or other fitness to practise incidents can be downloaded here.
FP10PCD Submission Document.
Pharmacy contractors in England are required to submit the original FP10PCD form to NHS Prescription Services for audit purposes each month using a special submission document, FP34PCD. The equivalent original forms originating from Wales or Scotland should also be submitted. The submission document can be downloaded from the NHS Prescription Services Website here.
GP Notification form (CFC containing Beclometasone inhalers)
To download a notification template form for alerting a GP Practice / Prescriber to the discontinuation of standard CFC containing beclometasone inhalers click here.
Hours Notification form.
Forms for applying for a change in a contractor’s core hours or notifying a PCT of a change in a contractor’s supplementary hours can be downloaded here.
Minor Relocation
The Department of Health has provided some assistance to PCTs on Control of Entry, contractors may use Annex D of the guidance (although not mandatory) for applications to the PCT including Minor Relocation. The guidance can be found here.
MUR Form.
The new MUR form can be downloaded here.
MUR PREM1 & PREM2 Forms:
Pharmacy contractors must self-certify to their PCT that their consultation area meets the required standard before beginning to conduct MURs. The Premises Self-Certification Form (PREM1) and the form to apply for PCT consent to conduct an MUR away from a Pharmacy (PREM2) can be downloaded here.
The PREM 1 form can be downloaded here.
The PREM 2 form can be downloaded here.
Patient Survey (Community Pharmacy Patient Questionnaire):
Details of organisations providing support with undertaking the survey are available here.
PNA Pharmacy Questionnaire:
PSNC has prepared a template for the PNA pharmacy questionnaire. This is intended for use in discussions between the LPC and the PCT, but in some cases, a PCT may ask pharmacy contractors to acceess this template and complete it for return to the PCT. This can be downloaded here.
Practice Leaflet:
A summary of the practice leaflet requirements and a template leaflet can be found here.
Prescription Charge Card:
PSNC distributes a prescription charge card that can be displayed in pharmacies to inform patients of the current prescription charge. Pharmacy Wales publish a Welsh version of the card. The charge card be downloaded here.
Pre-Registration Training Grant Form:
PSNC has developed a form which pharmacy contractors can use to apply to their PCT for payment of the Pre-Registration Training Grant.
The form can be downloaded here.
Safety alert record sheet:
PSNC has produced a template record sheet to assist those contractors who wish to make a record of the alerts that have been acted upon and filed. The form can be downloaded here.
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