Invoicing details form
Please provide details of where the invoices for monthly prescribing costs (reimbursement) and
dispensing fees (remuneration) should be sent for payment, including details the appropriate person
within your organisation to receive these invoices.
Once completed, please return this form to: [email protected]
Section A – Billing method
Please select one option for invoice delivery:
Email
Post
(for sustainability reasons, this is our preferred method)
Section B – Billing details
If you have selected to receive your invoice by email, please detail the recipients below:
Name:
Job title:
Email address:
Name:
Job title:
Email address:
Name:
Job title:
Email address:
Name:
Job title:
Email address:
V1.0
If you have chosen to receive your invoices by post, please detail where they should be sent to:
Organisation name:
Organisation code:
Department responsible for
payment:
For the attention of:
Full billing address:
Contact name (in the event
of any queries):
Contact telephone (in the
event of any queries):
Section C – Payment queries
In the event that we need to contact your organisation in relation to payment of your invoices, please
provide details of the appropriate person/people below:
Name:
Job title:
Telephone number:
Email address:
Name:
Job title:
Telephone number:
Email address:
Name:
Job title:
V1.0
Telephone number:
Email address:
Name:
Job title:
Telephone number:
Email address:
V1.0