Solicitors/Insurance/Other Company Requests - (This is NOT for Patient USE & will NOT be accepted)”

PLEASE NOTE WE ONLY ACCEPT REQUESTS FOR REGISTERED PATIENTS

Patients Details

Name

Address

Date of Birth

Phone Number

Further Information

Please choose one of the following that represents your request:

Solicitor SAR Request - (Your request will be responded to within one month of the request being received at the Practice)
Insurance company - (These requests are classed as private work and are to be carried out by one of the GP’s at the practice and there will be a charge of Approx £150.00 depending on request)
Court Order – (We will aim to meet the date specified within the court order provided adequate notice is given (at least 48 hours’ notice excluding weekends)
Coroner Requests – (These requests will be prioritised and responded to within an adequate timeframe)
Private Foster/ Adoption Medicals - (These requests are classed as private work and are to be carried out by one of the GP’s at the practice and there will be a charge of Approx £86 for a full medical and £28 for an update. Torfaen Council requests will fall under the collaborative fees.)
Army – (These requests are classed as private work and are to be carried out by one of the GP’s at the practice and there will be a charge Approx £50.00.)
Other - (These requests are classed as private work and are to be carried out by one of the GP’s at the practice and there will be a charge.)

Please give full details of your requirements.

Company Contact Details

Point of Contact Name

Telephone Number

Email Address

The GP’s will complete this work outside of their dedicated NHS time, so there will be a wait for completion of your request, this could be up to 30 working days.

Please do not contact us regarding your request until after this time.

We do not carry out URGENT private work and you will need to source other services for this. There will be a charge for all services that do not fall under NHS work, these will vary and could be subject to change. We have indicated an estimate of costs within this form. Payments are by BACS and details will be shared when the request is completed.

Please insure you understand the conditions that we have noted before submitting your request.

Please confirm that you agree to the conditions noted:

Yes

Please attach your formal letter/ request.

Please attached the patients consent.

Cwmbran Village / Llanyravon Surgery