Patient Application Form

To purchase a Prescription Pre-payment Certificate (PPC), please complete the following:

IMPORTANT - check whether you can get free prescriptions before filling in the form. Remember people 60 or over get free prescriptions.

To see if you can get free prescriptions, look in leaflet HC11, ‘Are you entitled to Help with Health Costs’, at:
www.ppa.org.uk/ppc/pdfs/HC11_hwhc.pdf

PPC Cost

The current cost is:

• £34.65 for a 4-month PPC; and


• £95.30 for a 12-month PPC.

Conditions of Issue

You can only use the PPC for your own NHS prescriptions.

Your PPC will start on the date you complete your application, unless you ask for a different start date. This can be up to one month earlier or later than the date you complete your application.

You can claim a full refund of the cost of a 4 or 12 month PPC if, within the first month, you become entitled to free prescriptions.

You can claim a partial refund of the cost of a 12 month PPC if, within months 2-4 of the PPC, you become entitled to free prescriptions.

For full details on PPC refund arrangements, including the time limit for claiming a refund, check leaflet HC11 at:
www.ppa.org.uk/ppc/pdfs/HC11_hwhc.pdf

Refund of Prescription Charges

Remember to apply for a new PPC in good time, otherwise you will have to pay charges when your old PPC runs out. If you claim you have a valid PPC when you do not, you may have to pay a penalty charge.

If you have to pay a prescription charge while you are waiting for your PPC, you cannot get a refund unless you get an NHS receipt form (an FP57) and your new certificate covers the date you paid the charge. When you apply, you can ask for your PPC to be backdated up to one month.

The pharmacist or dispensing doctor can only issue an FP57 at the time you pay a prescription charge; they cannot give you one later. The FP57 tells you how to get a refund.

Please Note

If you have not read our statement relating to the use of your personal information, please do so now.

Fields marked are mandatory. Please complete all mandatory fields.

Personal details should be those of the person who requires the certificate. This can be different from the person making payment.

If you require assistance in completing this form please call our Customer Contact Section on 0845 601 8076 between 8 am and 6 pm.

Personal Details
Title		Mr.   Mrs.   Miss   Ms.   Other Rev Dr Sir Sist Prof Fath Bro. Lord Lady Brig Capt Col Fr Gen Hon Lt.C Maj Sr Earl Cmdr Visc.
First Name
Surname
Address Line 1
Address Line 2
Address Line 3
Address Line 4
Post Code
Date of Birth		( dd/mm/yyyy )
NHS Number
Telephone Number		( Please enter only numeric characters, without spaces. )
Email Address
		Please ensure your Email address is entered correctly. We will send an Email, including your sales reference number, to this address once your order is accepted.
Previous Certificate		If you are renewing a Prepayment Certificate or have had one in the last 12 months, please enter the details here
Certificate Held
Certificate Number		( Please enter only numeric characters, without spaces. )
Certificate Expiry Date		( dd/mm/yyyy )
New Certificate
Certificate Duration		4 months 12 months
Start Date		( dd/mm/yyyy )
Payment
Card Type		Mastercard Delta Visa Switch Solo Visa Electron
Card Number		( Please enter only numeric characters, without spaces. )
Card Holder Name
Card Start Date		Month 01 02 03 04 05 06 07 08 09 10 11 12   Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Card Expiry Date		Month 01 02 03 04 05 06 07 08 09 10 11 12   Year 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Issue Number
Accept Terms of Sale		To proceed you must accept the terms of sale. To view the terms please click on the link below