INVOICE

ALL FORMS MUST BE TYPED AND NOT HAND WRITTEN. THEY MUST ALSO BE COMPLETD IN FULL. FAILURE TO DO THIS WILL RESULT IN PAYMENT DELAYS OR NON PAYMENT

For HEKSS Use Only

Invoice Number / 16ASK535-ES-
Invoice Date / / / / / 1 / 6
PO Number / XXSSMITH
Practice Name / FAO
Address Line 1
Address Line 2
Address Line 3
Town/City
Post Code
Health Education England – T73
KSS LETB
T73 Payables F485
Phoenix House
Topcliffe Lane
Tingley
Wakefield
WF3 1WE
Bank Account Number / Bank Account Sort Code / PAYABLE TO / Swift code
(overseas only) / E-mail address for
remittance advice

NOTE: PLEASE ENSURE BANK DETAILS ARE ENTERED. FAILURE TO ENTER THESE DETAILS WILL RESULT IN THE REMITTANCE BEING MADE BY CHEQUE, WITH INEVITABLE PAYMENT DELAYS.

Total Value of the Claim / £

Please fill in the breakdown of the claim on the following page

Details of the claim

CLAIM PAYABLE TO GP TRAINERS FOR ACTING AS EDUCATIONAL SUPERVISORTO GP ST1 / 2 TRAINEES or BBT CT2s FROM AUGUST 2016 to JULY 2017 - £500 per annum per trainee when trainee is based outside of the practice (pro rata)
Criteria for payment:
  • GP Trainers (ES) responsibility for GPST1/GPST2 trainees ONLY, from Aug 2016-July 2017
  • Educational Supervision of a trainee when the placement is outside of theGP practice
Practices are asked to submit one claim form for alleligible ES grants - completing one line per trainee below. Claim not applicable to GPST3 or F2 trainees
Practice Name:
Trainer Name (ES): / GP Trainee Name
(Full Name preferably as registered on RCGP ePortfolio) / GMC No
(essential data) / Trainee Grade(GPST1/2) / Supervision period from: / Supervision period to: / Amount Claimed
TOTAL CLAIMED / £
To be completed by the Practice
Claimant Declaration: I declare that the details pertaining to the above Educational Supervisors Grantfor the formentioned trainees are correct. I also understand that any fees are paid gross and that I am responsible, where appropriate, for declaring this income for tax purposes.
Name: Role:
Signed: Date:
This form then needs to be returned to the HEEKSS LETB by: 30 November 2016
Return either by post to Sue Smith, Health Education England, Crawley Hospital, 3rd Floor, Red Wing,
West Green Drive, Crawley, RH11 7DH
Or as a completed, signed scanned copy to
To be completed by HEEKSS :
Certification of verification: I have checked this claim and am satisfied that the is correct.
Name:
Signed:
Date:
Authorised By :Sue Smith
Position:Primary Care Placements Manager
Department:General Practice
Signed: Date: