Leeds Community Pharmacy Supervised Consumption Enhanced Service

							                                  Leeds City Council
                              Quarterly Claim Form SC2
         Leeds Community Pharmacy Supervised Consumption Enhanced Service 2011

To:   WYCSA 2 – 8 Brunswick Court, Bridge Street, Leeds LS2 7RJ
From: Pharmacy Stamp




Claim Period
Year:
Quarter:     April/June          July/September October/December           January/March

Methadone          Month 1      Month 2        Month 3      Total     number Payment Amount (number
                                                            supervisions     of supervisions x £1.45)
No. clients per
month
No.
supervisions
per month

Buprenorphine Month 1           Month 2        Month 3      Total     number Payment Amount (number
                                                            supervisions     of supervisions x £2.85)
No. clients per
month
No.
supervisions
per month


Total payment amount for Methadone & Buprenorphine



Please return the SC1 monthly monitoring forms with this claim.
Payment can only be issued with fully completed SC1 & SC2 forms.

Declaration
I declare that to the best of my knowledge this information is correct and I claim the appropriate payment.

Signed: …………………………………….                           Date: …………………………..

Payment will be made ¼ ly via the Prescription Pricing Division under ‘local payment scheme 1’. Please send
two completed copies of this form to WYCSA