Updated February 2020

	
St Cuthbert’s Church
Hayling Avenue
Portsmouth
PO3 6BH

Tel No: 023 92 827132	
POLICY FOR PRIVATE WORK, FEES & APPLICATION FORM

Please note that we do not sign passport or driving licence applications or photos and we will not confirm fitness to exercise, fly, drive, parachute jump, dive or climb mountains.
There are times when our service users ask for Doctors to provide things outside of the contractual obligations with the NHS.  These include reports and services where the doctors may set their own fees.  We ask that you complete the boxes below with as much information as possible to help us calculate the cost for you.  The Secretaries can be contacted for assistance if you need help completing the form; Option 4 on our main telephone menu during their working hours.

We will check your application and confirm the cost of the service you have applied for.  Once you have signed this form and paid the fee, we will aim to complete your request for Private Medical work within 20 days.  This timescale commences once all necessary consents and payments have been received. PLEASE ENSURE THIS TIMESCALE IS SUITABLE BEFORE YOU COMMIT YOUR PAYMENT AS REFUNDS WILL NOT BE POSSIBLE ONCE REQUEST IS UNDERWAY. If you have any special circumstances you would like us to be aware of, please include these below.  If there is likely to be a delay of any sort, we will usually telephone you to keep you informed.  Your signature consents to release of information to a third party where you have requested this.
PLEASE RETURN THIS FORM (ONCE SIGNED) TO EAST SHORE PARTNERSHIP, ST CUTHBERT’S CHURCH, HAYLING AVENUE, PORTSMOUTH PO3 6BH EITHER IN PERSON OR BY POST

Patient/Company Name:

Date Submitted:	Address:	Telephone number to contact you on:	
Private Work required, in your own words:

	Reasons for work, in your own words:	Patient/Company signature for consent to share information where requested and acceptance of fee to be incurred:
________________________	

BELOW THIS LINE IS FOR OFFICIAL USE ONLY:
Fee checked by DF/Secretaries : __
Patient Notified of Fee by Telephone __ Letter __	

Work Assessed as:
	Assessment of Fee:	Date Signed Form Returned:	
Date Completed:			
Patient feedback (please use back of this form):               EXPIRY DATE: _____________________