You can pick up an HC5 claim form 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
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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.
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