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FOUR TIMESTablets 250 mgTWO TO BE TAKENA DAY, Quant. 2*28i

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PATIENTS - please read the notes overleaf

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5G9648?2560 FP10ss0608

Should you pay prescription charges? Read all the statements in Part 1

opposite. You don't have to pay a prescription charge if any of the statementsapply to you (the patient) on the day you are asked to pay. (A valid War Pensionexemption certificate only entitles you to free prescriptions for your accepteddisablement.) Put a cross in the first box in Part 1 that applies to you, read thedeclaration and complete and sign Part 3.

Benefits which DO NOT provide exemption. You are NOT entitled toexemption from prescription charges because you receive Pension CreditSavings Credit, lncapacity Benefit, Disability Living Allowance, Contributionsbased Jobseeker's Allowance or Contributions based Employment and SupportAllowance. Only those benefits listed in Part 1 provide exemption. An HC3certificate does not entitle you to free prescriptions.

Evidence. You may be asked to provide evidence to show that you do not haveto pay. You could show the relevant benefit award notice, or an exemption orpre-payment certificate. lf you cannot show evidence at that time you can stillget your prescription items free but your Primary Care Trust will check yourentitlement later if you do not show proof (see paragraph about Penalty Charges).

lf you have to pay a prescription charge. You (or your representative) shouldput in Part 2 the amount you have paid and then sign and complete Part 3.

Need help with the cost of prescription charges? You can get information byringing 0845 850 1166 or by reading leaflets HC1 1 or HC12. You may be able toget these leaflets from your GP surgery or pharmacy. Or ring 0845 510 1 1 12 toget one, or go to www.dh.gov.uk/helpwithhealthcostsNot entitled to free prescriptions? Pre-pay to reduce the cost. lf you think youwill have to get more than 4 items in 3 months or 14 items in 12 months;t willbe cheaper to buy a pre-payment certificate (PPC). Phone 0845 850 0030 tofind out the cost, or order a PPC and pay by credit or debit card. You can payfor a 1 2 month PPC by direct debit instalment payments. Buy on-line atwww.ppa.org.uk To pay by cheque get an application form (FP95) from yourpharmacy or go to www.dh.gov.uk/helpwithhealthcosts The FP95 tells youwhat to do.

Do you need a refund? lf you are unsure if you are entitled to freeprescriptions you should pay for the prescription item(s) and ask for a receiptform FP57. You must get the FP57 form when you pay for the item(s), youcannot get the form later. lf you find you didn't have to pay, you can claimyour money back up to 3 months after paying, The FP57 form te ls you whatto do.

Patient Representative. lf you are unable to collect your prescription yourself,someone can take your completed form for you. You must complete Part 1.

Your representative must complete Parts 2 and 3. Anyone who collects aSchedule 2 or 3 controlled drug must sign the box in Part 1 when they collectthe item(s) and provide proof of identity if requested.

Data collection. Information about the prescription items on this form will beprocessed centrally to pay monies due to the pharmacist, doctor or appliancecontractor for the items they have supplied to you. The NH5 will also use theinformation to analyse what has been prescribed and the cost. The CounterFraud and Security Management Service, a division of the NHS Business ServicesAuthority, may use information from this form to prevent and detect {raud andincorrectness in the NHS.

Penalty Charges. lf it is found that you should have paid for your prescriptionitems, you will face penalty charges and may be prosecuted under the powersintroduced by the Health Act 1999. Routine checks are carr;ed out onexemption claims including some where proof may have been shown. You maybe contacted in the course of such checks.

FP10SS0608

:'l,mn*I who pay must fill in-paits 2 and 3. Penalty c-harges may be applied if you make a wrongful claim l

i for free prescriptions. lf you're unsure about whether you are entitled to free prescriptions, pay

l-91! ask for an FP57 form. You cannot get one later. The FP57 tells you alcfut getting a refunl

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is 16, 17 or 18 and in full-time education

is 60 years of age or over

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! fras a valid maternity exemption cerlificate

has a valid medical exempticn certificate

! has a valid prescription pre-payment certificateC * o""Z

! has a valid War Pension exemption certificate e <

! is named on a current HC2 charges certificate "4." "*d .

! was prescribed free-of-charge contraceptives Lf l *gets lncome Support or income-related Employment and It l Support Allowance

I *g"ar income-based Jobseeker's Allowance

L] *is entitled to, or named on, a valid NH5 Tax Credit Exemption Certificate

I I *nas a partner who gets Pension Credit guarantee credit (PCGC)

an awaid Jobseeker'sand SupportAllowance, lncome Support, Pension Credit Guarantee Credit or Tax Credit. .

Print the name of the pe6on who gets the benefit.

Declaration For patienl who do not have to payI declare that the ;n{ormation I have given on this form is correct and complete.I understand that if it is not, appropriate action may be taken. I confirm properentitlement to exemption. To enable the NHS to check I have a valid exemption andto prevent and detect fraud and incorrectness, I consent to the disclosure of relevantinformation from this form to and by the NHS Business Services Authority, theDepartment for Work and Pensions and Local Authorities.

Now and fill in Pari 3

and address*i

*lf different from overleafL Postcode

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The patient doesn't have to pay because he/she: i

Collectors of Schedule 2 & 3 lis under 16 years of ase i3!li,i"io"j,iii .ril,""'",i"]

Now sign and fill in Part 3

CrosoNrbox I am the patient

Print name r