Registration form - Solihull Healthcare Partnership

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Family doctor services registrations

Please complete as fully as possible. Please skip the sections that do not apply to your situation. Please fill in one form per family member you are registering.

Title*

Surname*

First Names*

Previous Surname/s

Date of Birth*

NHS Number

Town and country of birth*

Gender*

Next of Kin

Please help us trace your previous medical records by providing the following information.

Home Address*

Postcode*

Home Number

Mobile Number

Do you consent to receiving text messages for the provision of health and social care from Solihull Healthcare Partnership?

Yes

Your previous address in the UK*

Name of previous doctor while at that address*

Address of previous doctor*

If you are from abroad

Please leave this section blank if this does not apply to you

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

If you are returning from the Armed Forces

Please leave this section blank if this does not apply to you

Address before enlisting

Service or Personnel number

Enlistment date

NHS Organ Donor registration

For more information, please visit the website www.uktransplant.org.uk, or call 0300 123 2323

I want to register my details on the NHS Organ Donor register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

Please tick to confirm consent to inclusion on the NHS Blood Donor register

Supplementary Questions

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK (Please skip if this does not apply to you)

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indeinite leave to remain’ in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient lealet, available from your GP practice. You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided. Please tick one of the following boxes:

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section i f you have an EHIC issued by the UK.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

Do you have a non-UK EHIC or PRC?

Yes

Country Code

Name

Given Names

Date of Birth

Personal Identification Number

Identification number of the institution

Identifcation number of the card

Expiry Date

PRC Validity Period (a) From

PRC Validity Period (b) To

Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

If you are able to, please upload a copy of your proof of residence

This copy WILL NOT be stored and once verified will be suitably deleted in line with GDPR

This field should be left blank