Save moneyon NHS

prescriptioncharges

FP95

A prescription prepaymentcertificate (PPC) could save

you money on yourprescriptions

HowtobuyaPPC

• Online at:www.nhsbsa.nhs.uk/ppc

• Call:0300 330 1341

• Fill in this form and sendit to:

NHSBSAPPCBridge House152 Pilgrim StreetNewcastle Upon TyneNE1 6SN

If you want to buy a 12 month PPC you canpay monthly instalments by Direct Debit.

Check first to see if you can get freeprescriptions.

More information:

Website: www.nhs.uk/healthcosts

Phone: 0300 330 1343

Is a PPC right for me?

A prescription prepayment certificate workslike a season ticket.

If you need more than 12 prescribed medicineseach year, you could save money with a 12month PPC.

You can also buy a three-month PPC, whichwill save you money if you need more thanthree prescribed medicines in three months.

How much can I save?

Note: These savings are as calculated on 1 April 2015 and can change each year.

For current PPC prices go towww.nhsbsa.nhs.uk/ppcor call 0300 330 1341.

Number ofprescribed

medicines youneed eachmonth

Saving witha 12-month

PPC

Saving with athree-month

PPC

2Over £90a year

Over £20 inthree months

3Over £190a year

Over £40 inthree months

4Over £285a year

Over £65 inthree months

Terms and conditions

• You can only use the PPC for your ownNHS prescriptions.

• If you buy a 12 month PPC and pay byDirect Debit, you are agreeing to pay allthe instalments.

• If you miss an instalment you must returnthe PPC. If you do not return the PPC, wewill take further action.

• If you use the PPC after failing to pay aninstalment, you may have to pay apenalty charge.

• We cannot send you your PPC until wehave received your first payment.However, you may be able to claim arefund of prescription charges you haveto pay while you are waiting for it.

• You may be able to claim back the cost ofthe PPC if you become exempt from NHSprescription charges in England while youhave a current PPC.

• For full details of how to apply for arefund, including the time limit forclaiming a refund, go towww.nhsbsa.nhs.uk/ppcrefunds or phone0300 330 1343.

Claiming back prescriptioncharges

When you apply for a PPC, you can ask for itto be backdated by up to one month. If youhave to pay a prescription charge while youare waiting for your PPC, you can get arefund if you ask for an NHS receipt (FP57)when you pay for your prescription. You canonly get an FP57 at the time you pay, youcannot get one later.

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Instruction to your bank orbuilding society to pay byDirect DebitPlease fill in the whole form using a ballpoint penand send it to: NHS BSA, PPC, Bridge House, 152Pilgrim Street, Newcastle upon Tyne NE1 6SN.

Service user number (SUN)

Name and full postal address of your bank orbuilding society

Names of account holders

Bank or building society account number

Branch sort code

Reference

Instruction to your bank or building societyPlease pay the PPC Issue Office of the NHS BusinessServices Authority Direct Debits from the accountshown above under the Direct Debit Guarantee. Iunderstand that this instruction may stay with thePPC Issue Office of the NHS Business ServicesAuthority and, if so, they will pass detailselectronically to you.

Date

Banks or building societies may not accept DirectDebit instructions for some types of account.

This form is only for people who live in England.We will process this form more quickly if you fill itin using black ink and write in block capitalsinside the boxes.Title Mr Mrs Miss Ms Other

Surname

First name

Date of birth

National HealthService number:

Where should we send your certificate?

(Please give your full address including postcode.)

House numberor name

Street

Town

Postcode

Phone number in case we need to contact you:

Email address if you want us to contact you by email:

The PPC will start from the date we get this form unless yougive a different start date below. This cannot be more thanone month earlier, or one month later, than the date we getthis form.

Payment (Please tick one box.) Do not send cash. Theamount you must pay is set by law.

How would you like to pay?

10 monthly Direct Debit instalments.

Important note: You can only pay by Direct Debit if you buya 12 month certificate.

Are you the account holder? No Yes

Please sign and date the declaration below then fill in theDirect Debit instruction on the right.

Cheque Postal order

Make your cheques or postal orders payable to the ‘NHSBusiness Services Authority’ and write your postcode on theback.

I have read the terms and conditions and I am aware of thecircumstances when I can ask for a refund and the time limitsthat apply.

Signed

Date

If you wish to buy a PPC using a credit ordebit card go to: www.nhsbsa.nhs.uk/ppcor call 0300 330 1341.

For pharmacy use only

Data Protection Act 1998: We will use the information you have provided on thisapplication form to process your application and prevent and detect fraud. We will notgive your personal information to anyone else unless we have to do so by law, ortransfer it outside of the European Economic Area. We may contact you to discuss yourapplication and our quality of service to you. We will delete your personal informationfrom our systems and files no later than seven years from when you bought thecertificate. For more details, please read the privacy policy statement atwww.nhsbsa.nhs.uk.

(Important - We need to knowthis so we can check you are notentitled to free prescriptionsbecause of your age.)

FP950415

Which certificate do you want to buy?(Please tick one box only.)

Three month certificate

12 month certificate

Date you would like the certificate to start from:

To: The Manager

Bank or building society

Address

Postcode

4 2 7 8 52

Signature

Direct Debit Guarantee

Tear out this guarantee andkeep it.

• This Guarantee is offered by all banksand building societies that acceptinstructions to pay Direct Debits.

• If there are any changes to the amount,date or frequency of your Direct Debitthe PPC Issue Office of the NHS BusinessServices Authority will notify you 5working days in advance of your accountbeing debited or as otherwise agreed. Ifyou request the PPC Issue Office of theNHS Business Services Authority to collecta payment, confirmation of the amountand date will be given to you at the timeof the request.

• If an error is made in the payment ofyour Direct Debit, by the PPC Issue Officeof the NHS Business Services Authority oryour bank or building society you areentitled to a full and immediate refundof the amount paid from your bank orbuilding society.

• If you receive a refund you are notentitled to, you must pay it back whenthe PPC Issue Office of the NHS BusinessServices Authority asks you to.

• You can cancel a Direct Debit at any timeby simply contacting your bank orbuilding society. Written confirmationmay be required. Please also notify us.

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OCSCODE F

PHARMACY NAME AND ADDRESS OR PHARMACY STAMP

Signature

Date Sold / /

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