Family Doctor Services Registration - GMS1

BEVAN HOUSE Family Doctor Services Registration – GMS1

Name(Required)

Prefix First Last

Previous surname/s

Gender(Required)

Please state which gender you identify as. (We are required to ask this question as part of the registration process)

Date of Birth(Required)

NHS Number

Town and Country of Birth(Required)

Address

Street Address City County Postcode

Phone

I consent for Bevan to contact me by:

SMS

Phone

Please tick all that apply

Please help us trace your previous medical records by providing the following information

Your previous address in UK

Street Address City County Postcode

Name of previous GP practice while at that address

Address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

Street Address City Postcode

If previously resident in UK, date of leaving

Date you first came to live in the UK

Were you ever registered with an Armed Forces GP?(Required)

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Street Address City County Postcode Country

Service or Personnel number

Enlistment date

Discharge date

If you need your doctor to dispense medicines and appliances*

I live more than 1.6km in a straight line from the nearest chemist

I would have serious diffculty in getting them from a chemist

*Not all doctors are authorised to dispense medicines

Signature of patient(Required)

Todays Date(Required)

Signature on behalf of patient

Todays Date(Required)

SUPPLEMENTARY QUESTIONS

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise, you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please tick one of the following boxes:

I understand that I may need to pay for NHS treatment outside of the GP practice.

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested.

I do not know my chargeable status.

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

Signed

Print Name

On behalf of

Relationship to parent

Date

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

Do you have a non-UK EHIC or PRC?

Yes

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

If yes, please enter details from your EHIC or PRC below:

Country Code (e.g. UK, DE etc.):

Country Code

Name

Date of Birth

Given Names

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

PRC validity period (from)

PRC validity period (to)

Please tick if you have an S1

Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

What is your ethnic group?

Please tick one box that best describes your ethnic group or background from the options below:

White

British

Irish

Irish Traveller

Traveller

Gypsy/Romany

Polish

Other

Mixed

White and Black Caribbean

White and Black African

White & Asian

Other

Asian or Asian British

Indian

Pakistani

Bangladeshi

Other

Black or Black British

Caribbean

African

Somali

Nigerian

Other

Other ethnic group

Chinese

Filipino

Other

If you selected other, please tell us here

Not stated

Not Stated should be used where the PERSON has been given the opportunity to state their ETHNIC CATEGORY but chose not to.