Application for Additional Payments During Confinement

LOC4 Q47 - Lancashire Area Team Application for Additional Payments during Confinement

Fill this form in and send it to Payments, PCSS (Preston Office), 3 Caxton Road, Fulwood, Preston, PR2 9ZZ together with a medical certificate for your confinement as soon as you have decided the date when you will give up work and you have made arrangements to engage a locum or deputy from outside the practice.

Before completing this form please refer to the guidance issued by the Joint Committee on Postgraduate Training for General Practice, which outlines the requirements when appointing a locum to cover your period of absence.

DETAILS OF GP APPLYING FOR ADDITIONAL PAYMENTS Surname: Initials: Local code number:

First day away from practice: Are you already receiving sickness payments under SFE 9? YES/NO

DETAILS OF LOCUMS OR DEPUTIES Surname: 1) 2) Forename: Address:

GMC Registration No. Are they on the NHS England performers □ Yes □ No □ Yes □ No list?

Name of Area Team: Personal number:

On what basis will they be employed: □ Full Time □ Full Time (locums count as full time if they work the normal hours, as approved by the Area Team of the practitioner they are deputising for)

□ Part Time □ Part Time Please give details Please give details

When will they start From: From: deputising for you as a locum or deputy? To: To:

of 2 1 LOC4 OTHER RELEVANT INFORMATION

Is there any other relevant information that might affect this Yes No application? □ □

Please give details

DECLARATION OF THE GP APPLYING FOR PAYMENTS

I declare

 That I intend to resume practice as a principle under the nGMS contract, provided that I am fit, within a reasonable time of the birth of my child.  That the information on this form is correct.  I undertake to inform the Area Team of any change in my deputising arrangements without delay. I apply for additional payments under SFE 9. I enclose a medical certificate for my confinement.

Signature:

Practice Stamp:

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