<p> Antimicrobial Prescribing Audit for Dentists in Wales</p><p>AMP 4 Claim Form</p><p>This form should be completed when claiming funding. Please submit your claim form in Hard Copy and send to Nicola Dempsey to the address below.</p><p>Your Name and Initials</p><p>Local Health Board</p><p>GDC Registration Number</p><p>LHB Contract Number</p><p>NHS Performer Number Please tick if NOT an NHS Dentist</p><p>Payment Details No of hours claimed 3 hours @ £65.07/hour £ 195.21</p><p>(N.B All NHS Contract Numbers for the duration of the audit must have been open in order to receive funding) </p><p>Total Claim £ 195.21</p><p>Claim Form Declaration </p><p>I declare that (please tick boxes below) </p><p>I confirm that I have undertaken a prescribing audit and completed 20 AMP 2 forms or have collected prescribing data for a period of three months. I understand that I am liable to declare payments to the Inland Revenue and that Income Tax and NI will NOT be deducted on my behalf from the amounts claimed above. I confirm that my NHS contract number was open for the duration of the audit.</p><p>Signature of Claimant Date</p><p>Verification and Payment Approval: I certify that the above named dentist has satisfactorily completed the Antimicrobial Prescribing Audit above in accordance with the guidance issued by the The Dental Postgraduate Section, Wales Deanery and with 1000 Lives Plus Welsh Assembly Government.</p><p>Examined & Verified by</p><p>Signature Date Director/Deputy Director of Dental Postgraduate Education in Wales Any queries with regard to the payment process should be directed to the Dental Postgraduate Section. </p>