MA electronic claim form by gems1494

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									                                                                 MINOR AILMENTS CLAIM FORM
                                                              COUNTY DURHAM & DARLINGTON PCTs
                                                                                  Month of claim:
Pharmacy Details:                                                                                                                             PPA no:
                                                                                  Unique Inv No:
                                                          Cost per       No.of    Total Cost                                                             Cost per      No of        Total
                                                         item (excl      items    (excl VAT)                                                            item (excl     items      Cost (excl
                Product supplied                PIP Code                                                       Product supplied                PIP Code
                                                            VAT)                                                                                           VAT)                     VAT)

Beclomethasone nasal spray 200 dose             109-8417      £2.50                  £0.00     Ibuprofen 200mg Tablets x 24                   024-0564      £0.42                   £0.00
Cetirizine 10mg Tablets x30                     109-9209      £1.17                  £0.00     Ibuprofen 100mg/5ml s/f Suspension x100ml      107-0176      £1.05                   £0.00
Cetirizine solution 1mg/ml x100ml               292-4892      £2.97                  £0.00     Loperamide capsules x6                         108-1595      £1.24                   £0.00
Chlorphenamine 4mg Tablets x30                  107-6132      £0.58                  £0.00     Malathion aqueous liquid 2x50mls               228-1434      £4.73                   £0.00
Chlorphenamine 2mg/5ml Oral Solution x150 ml    110-0080      £1.32                  £0.00     Mebendazole tab 100mg x 1                      002-8266      £1.71                   £0.00
Clotrimazole cream 1% x 20g                     253-3099      £1.77                  £0.00     Menthol and Eucalyptus inhalation 100ml        027-2625      £0.93                   £0.00
Clotrimazole pessary 500mg x 1                  112-6275      £2.20                  £0.00     Paracetamol 120mg/5ml s/f Suspension x200ml    200-8548      £0.86                   £0.00
Co-magaldrox 500ml                              020-9957      £2.79                  £0.00     Paracetamol 250mg/5ml s/f Suspension x200ml    106-5515      £1.41                   £0.00
Dimeticone 4% lotion 2x50 ml                    317-4166      £5.95                  £0.00     Paracetamol 500mg Tablets x32                  107-4657      £0.18                   £0.00
Dioralyte sachets x 6                           005-0294      £2.11                  £0.00     Peptac Liquid x 500ml                          214-5621      £1.95                   £0.00
Fluconazole capsule 150mg x 1                   297-4590      £3.81                  £0.00     Piperazine oral powder x 2 dose sachet         038-9627      £1.73                   £0.00
Gaviscon Tablets x16                            281-6783      £1.49                  £0.00     Senna tablets x 20                             108-5216      £0.96                   £0.00
Hydrocortisone cream 1% x 15g                   104-3512      £0.93                  £0.00
SUB TOTAL (1)                                                                        £0.00     SUB TOTAL (2)                                                                        £0.00
  I CERTIFY THAT THIS CLAIM IS ACCURATE AND CLAIM THE TOTAL OF:                                Total Drug Cost =                                                                    £0.00
                                                                                               VAT on Drugs @ 15% =                                                                 £0.00
                                         £0.00                                                                         TOTAL DRUGS PAYMENT incl VAT (a) =                           £0.00
                                                                                               GP Referrals Non Urgent
FOR THE MONTH OF:
                                                                                               Rapid Referral to GP – same day

NAME:
                                                                                               Staff Consultations                                          £4.25                   £0.00
                                                                                               VAT on staff consultations @ 15% =                                                   £0.00
SIGNATURE:
                                                                                                                   TOTAL CONSULTATION PAYMENT incl VAT (b) =                        £0.00

DATE:                                                                                                                    TOTAL PAYMENT CLAIMED (a+b)                                £0.00

            Please complete all coloured areas of the form (where applicable) and return completed claims forms by 15th of the month together with your invoice for payment to:
                                          Yvonne Wanless, Accounts Payble Supervisor, County Durham & Darlington PCTs,
                                             Henson Close, South Church Enterprise Park, Bishop Auckland DL14 6WA




                                                                                                                                                                           revised 1.08.09
                                                                                                                                                     Medicines Management (Commissioning)
                                                                                                                                                                        01.08.09-31.08.09

								
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