Patient Registartion form - Rush Green Medical Centre

Patient Registration Online Form

Please enable JavaScript in your browser to complete this form.

To register yourself or someone else with a GP surgery, fill in this form and submit.

You should:

• use a ‘tick’ or ‘x’ for boxes where necessary
• complete all sections that apply to you or the person you are registering
• provide as much information as possible
• use BLOCK CAPITALS
• if you cannot answer a question or it does not apply write ‘Not applicable’ or ‘N/A’
• only use black or blue ink
• ask at the reception desk of the surgery you want to register with if you need help completing this form.

Which sections should be completed?

• Part A - all sections that apply.
• Part B - this section is optional, but will help the GP
provide the best care.
• Part C - only complete these sections if you do not
normally live in the UK.
You may be contacted by the GP surgery if you do not
complete all the relevant sections.

Register online

It is quick and secure to register with a new GP surgery online. Check the website of the surgery you want to
register with for a link for the ‘Register to a GP surgery’ service.

PART A

Try to provide as much information as possible. If a question does not apply to you or the person you are registering write ‘Not applicable’ or ‘N/A’.

Section 1 - Who is registering?

Yourself (Go to Section 2 - Patient details)
Someone else

Only provide your details if you are registering someone else

Your name

First

Last

Phone

Your relationship to the person you are registering

You can help save lives as a blood or organ donor. Become someone’s lifeline.
Visit www.nhsbt.nhs.uk/lifeline or call us on 0300 123 23 23.

PART C

Section 6 - Patients from abroad

Complete this section if you are:
• Visiting the UK and do not normally live here.
• Currently living in the UK, but do not think of it as your permanent country of residence. For example, you are studying here or have come to the UK as part of your job.
• A permanent resident in the UK and receive a pension or benefit from a European country

Information on eligibility to free care outside the GP practice

Anyone can register with a GP practice and receive free medical care from that practice. However, should you be referred for treatment outside the practice or need unplanned care, for example at a hospital, charges may apply if you are a visitor or temporary resident. Some groups of visitors or temporary residents are eligible to receive this care free of charge. Documentation may be required to demonstrate eligibility.

Examples of those eligible include:
• Refugees, asylum seekers, those receiving certain forms of state support
• Suspected or confirmed victims of modern slavery and human trafficking
• Temporary residents with a valid visa of over 6 months. You may have paid the immigration health surcharge with your visa application. Note that assisted conception services remain chargeable to this group
• Visitors from the EEA will need to provide their EHIC (European Health Insurance Card), which covers immediately necessary unplanned treatment, or a S2 form which covers planned treatment.

Additionally, some services are free of charge to all visitors, including diagnosis and treatment for infectious diseases and sexually transmitted infections.
Immediate necessary care, maternity care and other urgent care that cannot wait until a chargeable visitor’s departure from the UK will not be withheld or delayed due to charges. But non-urgent treatment will not be given until full payment is received.

More information can be found in the patient leaflet available from the GP practice

Select the statement that applies to you

I understand I may have to pay for NHS treatment outside of the GP practice.
I do not have to pay for NHS treatment outside of the GP practice and have documents to prove this.
I do not know if I have to pay for treatment

PART C

Section 6 - Patients from abroad (continued)

Giving us this information means that if you need NHS care outside the GP practice and you are entitled to that care without charge, it will be easier
for you to demonstrate this entitlement.
We’ll use the information to establish your chargeable status in order to recover NHS costs from countries responsible for your healthcare where
applicable. This will not impact your entitlement to register with the GP practice or to receive free GP services.

Tick one of the following

I have an S1 form issued by an EU or EEA member state
I am entitled to an EHIC card, but I do not have one
I have an EHIC card issued by an EU or EEA member state
I am in receipt of a European pension or benefit
I am in the UK as part of my employment
None of these

Enter details from your EHIC

Country code

Personal identification number

Name

Identification number of the institution

Given name

Identification number of the card

Date of birth DD MM YYYY

Expiry date DD MM YYYY

How will your EHIC and S1 data be used?

By using your EHIC for NHS treatment costs your EHIC 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 or S1 information will be
shared with Business Service Authority for the purpose of recovering your NHS costs from your home country.

5625260544

GP Training Practice

Patient Registration Online Form

To register yourself or someone else with a GP surgery, fill in this form and submit.

You should:

Which sections should be completed?

Register online

PART A

Only provide your details if you are registering someone else

You can help save lives as a blood or organ donor. Become someone’s lifeline.
Visit www.nhsbt.nhs.uk/lifeline or call us on 0300 123 23 23.

Section 2 - Details of patient registering

Section 3 - Patients under 18 years

For patients under 18 years

Section Divider

Section 4 - Additional information - What is your ethnic group?

Section 4 - Additional information

Section Divider

PART B

PART C

Section 6 - Patients from abroad

Information on eligibility to free care outside the GP practice

PART C

Section 6 - Patients from abroad (continued)

Enter details from your EHIC

How will your EHIC and S1 data be used?

GP Training Practice

Patient Registration Online Form

To register yourself or someone else with a GP surgery, fill in this form and submit.

You should:

Which sections should be completed?

Register online

PART A

Only provide your details if you are registering someone else

You can help save lives as a blood or organ donor. Become someone’s lifeline. Visit www.nhsbt.nhs.uk/lifeline or call us on 0300 123 23 23.

Section 2 - Details of patient registering

Section 3 - Patients under 18 years

For patients under 18 years

Section Divider

Section 4 - Additional information - What is your ethnic group?

Section 4 - Additional information

Section Divider

PART B

PART C

Section 6 - Patients from abroad

Information on eligibility to free care outside the GP practice

PART C

Section 6 - Patients from abroad (continued)

Enter details from your EHIC

How will your EHIC and S1 data be used?

You can help save lives as a blood or organ donor. Become someone’s lifeline.
Visit www.nhsbt.nhs.uk/lifeline or call us on 0300 123 23 23.