Doctor joining a cost centre
Authorised signatory should complete form and send to: [email protected]
Parent Org
name
Parent Org
code
Doctor details
Doctor prescribing code (DIN)*
Cost centre code
Doctor name (max. 28 characters
including spaces)
Surname:
Initial(s):
*If the doctor joining this cost centre is a hospital doctor (without a DIN) or a doctor who is using their DIN in
another GP practice/cost centre, please complete the ‘Spurious code request’ form.
Cost Centre details
Cost centre name (as shown on
ePACT.net, max. 40 characters
including spaces)
Address details (max. 25 characters per line including spaces)
Address line 1
Address line 2
Address line 3
(town or city only)
Address line 4
(county or London only)
Postcode
Telephone number
Start date
Authorised signatory:
Print name:
Contact number:
Date:
.For NHS Prescription Services use only
MDR input
(date & initials)
Version 3.2