You can pick up an HC5 claim form appropriate to the charge you paid (for example, HC5(D) to claim money back for NHS dental charges) from a Social Security office or NHS hospital. Your doctor, dentist or optician may have one too. You can also request a form by telephoning 0845 850 1166
 
 


If you have paid for Wigs/Fabric Supports then click here to download the claim form. If you wish to claim money back for any other charges then please complete the form below.

Your Personal Data

The Prescription Pricing Authority will only use the personal information provided on this on-line form to process your request for an HC5 claim form.

Your personal data will be sent via e-mail across the Internet to the PPA.
We will not disclose your Personal Data to any third party or transfer it outside of the European Economic Area.

The data entered on this form will be deleted no later than one calendar month from today.

Orange fields are mandatory - Please complete all mandatory fields. (also marked with a * for older browsers)
*Forename
*Surname
*Title
   

*Address		 (house number and street name)
*Town
County
*Postal Code
   


If you wish to claim money back for health costs you have already paid, please tick the box(es) appropriate to the charge(s) you have paid. We will send you the appropriate HC5 form which you should also complete.
Dental
Sight Test/Glasses/Contact Lenses
Travel for NHS Treatment

 

  
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