Supervision Claim Form - NHS Cumbria
Supervision Claim Form - NHS Cumbria
Supervision Claim Form - NHS Cumbria
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<strong>Supervision</strong> <strong>Claim</strong> <strong>Form</strong> Application for payment in respect of Supervised Administration of Methadone and Buprenorphine (Enhanced Service ES02)<strong>Claim</strong> for the Month of ______________________Payment will be based on the total number of monthly supervised doses I declare that for the above month:-a) The pharmacy was open 5/6/7 days each week (delete as appropriate)b) The doses were supervised as listed below and marked (M) or (B)c) There is a Standard Operating Procedure for supervision arrangementsd) The service complies with Community Pharmacy Enhanced Service Specification ES 02.Client CodeDaysof theMonth1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31TotalNumber ofAdministrationsTotal no. M X £1.60 =Total no. B X £3.60 =Total payment =Name of Pharmacist providing Supervised Administration Services (please print) ............................................................Signed ..................................................... Date ................................... KEEP COPY IN PHARMACY FOR 2 YEARSPlease return to: - Contractor Services, <strong>NHS</strong> <strong>Cumbria</strong>, Tenterfield, Brigsteer Road, Kendal LA9 5EA by 7 th month
<strong>Supervision</strong> <strong>Claim</strong> <strong>Form</strong> Please return to: - Contractor Services, <strong>NHS</strong> <strong>Cumbria</strong>, Tenterfield, BrigsteerRoad, Kendal LA9 5EA by 7 th month
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