February 2017
Greater Huddersfield and North Kirklees CCG
Prescription Pre-Payment Certificate (PPC) Refund Application Form
For Kirklees patients who have previously been prescribed products in 2017 that the CCG no longer routinely fund on prescription and who have outstanding full months left on their PPCs after 1st February 2017.
The offer of a PPC refund does not apply to patients who pay for them by monthly direct debit. In these cases, the PPC can be returned to the NHS Business Services Authority with a letter stating it is no longer required and cancel the direct debit.
All claims must include the original Prescription Pre-Payment Certificate (card) and be received before 1st July 2017
Patient’s Name as stated on PPC:Patient’s Address:
Contact Phone number or email address:
Patient’s GP Practice Name:
The pre-payment certificate (card) was for a duration of __ months and became effective on dd / mm / yyyy.
The last prescription obtained using the pre-payment certificate (card) was on
dd / mm / yyyy.
The refund will be posted as a cheque. Please state here the name of the person you would like the refund cheque to be made payable to:
The refund cheque will be posted to you at your above address unless you provide an alternative postal address here:
I declare that I am the above named patient and that the enclosed Prescription Pre-Payment Certificate (card) was purchased for the purposes of obtaining (eg gluten free foods)______on prescription from my GP.
I consent to the disclosure of information on this form to the Counter Fraud and Security Management Service, a division of the NHS Business Services Authority, for the purpose of prevention, detection, investigation and prosecution of fraud and any other unlawful activity affecting the NHS.
Signed: Date:
The amount to be refunded for outstanding full months left on their PPCs, will be calculated according to the below:
Number of complete months PPC still valid for: / 3 month PPC (£29.10)Refund Due: / 12 month PPC (£104.00)
Refund Due:
12 / na / £104.00
11 / na / £95.33
10 / na / £86.67
9 / na / £78.00
8 / na / £69.33
7 / na / £60.67
6 / na / £52.00
5 / na / £43.33
4 / na / £34.67
3 / £29.10 / £26.00
2 / £19.40 / £17.33
1 / £9.70 / £8.67
Please post the above application form, with all the details completed, with your Prescription Pre-Payment Certificate (card) (original only no copies) before 1st July 2017 to the following address (applications with a postal date after 1st July 2017 will not be considered):
PCC Application
Broad Lea House,
Bradley Business Park,
Dyson Wood Way,
Bradley.
Huddersfield. HD2 1GZ
For any questions about this refund application form or process please contact:
Vicky Dutchburn - Head of Strategy, Business Planning & Service Improvement; Greater Huddersfield CCG
Email: – please put ‘PCC application query’ in the subject box
or
Phone number: 01484 464091
Confidentiality
The information you have provided is kept strictly confidential by Greater Huddersfield CCG and North Kirklees CCG in accordance with the Data Protection Act. Your personal information will not be shared with any other agencies apart from NHS Business Services Authority.