South, South West
APPLICATION FOR ADDITIONAL PAYMENTS
LOC 7
DURING DOCTORS SUSPENSION

Please complete this form and send it to SFE Claims, Primary Care Team, NHS England, South,
South West, Peninsula House, Kingsmill Road, Tamar View Industrial Estate, Saltash PL12 6LE
Notes:

This claim is made in line with the current GMS Statement of Financial Entitlements 2013, Part 4
(Payments For Specific Purposes), Section 15.
 The maximum claimable is £1,131.74 per week
 Payments are only payable if the contractor satisfies the following conditions:The contractor must, on request, provide the NHS England with written records
demonstrating –
(i)
the actual cost to it of the locum cover, and
(ii)
that it is continuing to pay the suspended GP performer at least 90% of his normal
income before the suspension (i.e., his normal monthly drawings from the partnership
account, his normal salary or a pro rata amount in the case of part months).
DETAILS OF APPLICATION FOR ADDITIONAL PAYMENTS
Surname:
Initials:
Name of Practice:
NHS England code
number:
Number of Regular weekly sessions:
First day away from practice for which you
wish to claim additional payments:
Please state how long the Doctor has
worked for this PCT (previously the
H.A.)
………………………………………………………………
Is there any other relevant information
that might affect this application?
………………………………………………………
Date returning to work (if known)
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DECLARATION

The information I have given on this form is correct & complete and I understand that if it is not
action will be taken against me. Payment of these fees is applied for under the General Medical
Services regulations and specifically Part 4 of the current Statement of Financial Entitlements.

The practice is not claiming another payment for locum cover in respect of the absence under
another section in part 4 of the Statement of Financial Entitlements.

From 1st April 2015 improved maternity/paternity arrangements have been agreed, to cover both
external locums and cover provided by existing GPs within the practice who do not already work
full time

I undertake to inform NHS England of any change in my deputising arrangements without delay

The practice will submit claims for costs actually incurred after they have been incurred as soon
as possible after the end of the month during which the costs were incurred (NHS England will
make payments as soon as possible (normally within one month) following receipt of these
claims).

I agree that I will, if requested by NHS England, submit myself to an examination by a Doctor
nominated by NHS England, and that the examining Doctor can convey their opinion to NHS
England
Signature:
Date:
Practice Stamp:
If the contractor breaches any of the conditions of the General Medical Services regulations, Part 4,
Section 11 of the current GMS Statement of Financial Entitlements, NHS England may, in appropriate
circumstances, withhold payment of any sum otherwise payable under this section
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