Ophthalmic User Guide - PCSS Preston Primary Care Support
Contents
1. PART 2 PATIENTS DECLARATION TICK AS APPROPRIATE I E PATIENT OR PATIENTS PARENT CARER OR GUARDIAN ENSURE FORM IS SIGNED BY PATIENT PATIENT REPRESENTATIVE PROVIDE DATE AND PATIENTS NAME BLOCK CAPITALS PART 3 PRACTITIONERS DECLARATION PROVIDE DATE AND OUTCOME OF TEST VOUCHER TYPE IF APPLICABLE PRACTITIONERS SIGNATURE PRACTITIONERS NAME BLOCK CAPITALS DATE AND LIST NUMBER APPROPRIATE CLAIM DETAILS FULL DETAILS OF AMOUNT CLAIMED APPROPRIATE CODE IF TEST LESS THAN MINIMUM INTERVAL ADDRESS WHERE SIGHT TEST TOOK PLACE BLOCK CAPITAL PAYMENT ADDRESS WHERE PAYMENT SHOULD BE SENT IF DIFFERENT CONTRACTORS SIGNATURE CONTRACTORS NAME BLOCK CAPITALS LIST NUMBER AND DATE CONTRACTORS NAME AND ADDRESS BLOCK CAPITALS OR PRACTICE STAMP PCSS Preston2. BLOCK CAPITALS LIST NUMBER AND DATE CONTRACTORS NAME AND ADDRESS BLOCK CAPITALS OR PRACTICE STAMP PCSS Preston INHS England GUIDE TO COMPLETING A GOS 6 FORM THE FOLLOWING IS MANDATORY INFORMATION THAT NEEDS TO BE COMPLETED IN ORDER FOR THE FORM TO BE PROCESSED BY PRIMARY CARE SUPPORT SERVICES PRESTON PLEASE COMPLETE THE FOLLOWING DETAILS IN BLOCK CAPITALS PLEASE NOTE PRIOR TO CARRYING OUT A DOMICILIARY VISIT YOU MUST HAVE A CONTRACT WITH THE AREA TEAM WHERE THE PATIENT RESIDES AND PRIOR NOTIFICATION OF THE INTENDED VISIT MUST HAVE BEEN MADE TO PRIMARY CARE SUPPORT SERVICES PRESTON PART 1 PATIENTS DETAILS SURNAME FIRST NAME DATE OF BIRTH FULL ADDRESS WITH POSTCODE DATE OF LAST SIGHT TEST NOTE PLEASE ENTER AN EARLY RE TEST CODE IN PART 3 REVERSE OF FORM IF THE TEST IS PERFORMED EARLIER THAN THE MINIMUM INTERVAL REASON WHY PATIENT CANNOT ATTEND PRACTICE UNACCOMPANIED PLEASE TICK RELEVANT PATIENT ENTITLEMENT COMPLETE NAME AND ADDRESS OF SCHOOL COLLEGE UNIVERSITY IF PATIENT IS A STUDENT AGED UP TO 18 PARTNERS DETAILS IF PATIENT IS NOT THE ONE RECEIVING BENEFIT HC2 NUMBER IF APPLICABLE PROVIDE DETAILS OF THE LOCAL AUTHORITY IF PATIENT IS BLIND PARTIALLY SIGHTED GP IF PATIENT SUFFERS FROM DIABETES GLAUCOMA HOSPITAL IF PATIENT CONSIDERED TO BE AT RISK OF GLAUCOMA BY AN OPHTHALMOLOGIST PRISON IF PATIENT IS A PRISONER ON LEAVE FROM PRISON PCSS Preston INHS
3. LS PART 5 SUPPLIERS DECLARATION TICK AS APPROPRIATE I E PATIENT OR PATIENTS PARENT CARER OR GUARDIAN COMPLETE PRESCRIPTION IF LENS IS BEING REPLACED VOUCHER TYPE INCLUDING ANY SUPPLEMENTS TICK BOX AS APPROPRIATE TO VOUCHER VALUE PROVIDE FULL DETAILS OF AMOUNT CLAIMED OR RETAIL PRICE IF APPLICABLE SUPPLIER NAME DATE AND SIGNATURE SUPPLIERS NAME AND ADDRESS BLOCK CAPITALS OR PRACTICE STAMP PCSS Preston INHS England GUIDE TO COMPLETING A GOS 5 FORM THE FOLLOWING IS MANDATORY INFORMATION THAT NEEDS TO BE COMPLETED IN ORDER FOR THE FORM TO BE PROCESSED BY PRIMARY CARE SUPPORT SERVICES PRESTON PLEASE COMPLETE THE FOLLOWING DETAILS IN BLOCK CAPITALS PART 1 PATIENTS DETAILS SURNAME FIRST NAME DATE OF BIRTH FULL ADDRESS WITH POSTCODE DATE OF LAST EYE TEST TICK IN APPROPRIATE BOX PROVIDE HC3 NUMBER AND PAYMENT AMOUNT PART 2 PATIENTS DECLARATION TICK AS APPROPRIATE I E PATIENT OR PATIENTS PARENT CARER OR GUARDIAN ENSURE FORM IS SIGNED AND DATED BY PATIENT OR PATIENTS REPRESENTATIVE PROVIDE DATE AND PATIENTS NAME BLOCK CAPITALS PART 3 PRACTITIONERS DECLARATION DATE AND OUTCOME OF TEST VOUCHER TYPE IF APPLICABLE PERFORMERS SIGNATURE LIST NUMBER AND NAME BLOCK CAPITALS PROVIDE FULL DETAILS OF AMOUNT CLAIMED ADDRESS WHERE SIGHT TEST TOOK PLACE BLOCK CAPITALS OR PRACTICE STAMP COMPLETE ADJACENT DETAILS IF RELEVANT PERFORMERS SIGNATURE PERFORMERS NAME
4. NHS England Ophthalmic User Guide INHS England Contents GUIDE TO COMPLETING A GOS 1 FORM GUIDE TO COMPLETING A GOS 3 FORM GUIDE TO COMPLETING A GOS 4 FORM GUIDE TO COMPLETING A GOS 5 FORM GUIDE TO COMPLETING A GOS 6 FORM NHS England GUIDE TO COMPLETING A GOS 1 FORM THE FOLLOWING IS MANDATORY INFORMATION THAT NEEDS TO BE COMPLETED IN ORDER FOR THE FORM TO BE PROCESSED BY PRIMARY CARE SUPPORT SERVICES PRESTON PLEASE COMPLETE THE FOLLOWING DETAILS IN BLOCK CAPITALS PATIENTS DETAILS SURNAME FIRST NAME DATE OF BIRTH FULL ADDRESS WITH POSTCODE DATE OF LAST EYE TEST NOTE PLEASE ENTER AN EARLY RE TEST CODE IN PART 3 REVERSE OF FORM IF THE TEST HAS BEEN PERFORMED EARLIER THAN THE PERMITTED INTERVAL GOS MINIMUM SIGHT TEST INTERVALS ARE AS FOLLOWS Patients Age at Time of Sight Test or Clinical Minimum Interval Between Sight Test Condition Under 16 years in the absence of any binocular 1 year vision Under 7 years with binocular vision anomaly or 6 months corrected refractive error 7 years and over and under 16 with binocular 6 months vision anomaly or rapidly progressing myopia 16 years and over and under 70 years 2 years 70 years and over 1 year 40 years and over with family history of 1 year glaucoma or with ocular hypertension and not in monitoring scheme Diabetic glaucoma patients 1 year Regi
5. S England GUIDE TO COMPLETING A GOS 3 FORM THE FOLLOWING IS MANDATORY INFORMATION THAT NEEDS TO BE COMPLETED IN ORDER FOR THE FORM TO BE PROCESSED BY PRIMARY CARE SUPPORT SERVICES PRESTON PLEASE COMPLETE THE FOLLOWING DETAILS IN BLOCK CAPITALS PATIENTS DETAILS SURNAME FIRST NAME DATE OF BIRTH FULL ADDRESS WITH POSTCODE DATE OF PRESCRIPTION VOUCHER TYPE INCLUDING ANY SUPPLEMENTS PRESCRIPTION S PERFORMERS NAME LIST NUMBER SIGNATURE AND DATE PATIENTS DECLARATION PLEASE TICK RELEVANT PATIENT ENTITLEMENT NAME AND FULL ADDRESS OF SCHOOL COLLEGE UNIVERSITY IF PATIENT IS A STUDENT AGED UP TO 18 IF PATIENT IS NAMED ON A VALID HC2 OR HC3 CERTIFICATE PLEASE PROVIDE NUMBER AND THE VALUE THE VOUCHER WILL BE REDUCED BY FOR HC3 PROVIDE THE DETAILS OF PRISON IF PATIENT IS A PRISONER ON LEAVE FROM PRISON TICK AS APPROPRIATE I E PATIENT OR PATIENTS PARENT CARER OR GUARDIAN ENSURE FORM IS SIGNED AND DATED BY PATIENT OR PATIENTS REPRESENTATIVE ENSURE PATIENTS NAME IS COMPLETED IN BLOCK CAPITALS PCSS Preston INHS England SUPPLIERS DECLARATION COMPLETE DECLARATION PROVIDE FULL DETAILS OF AMOUNT CLAIMED OR RETAIL PRICE IF APPLICABLE SIGN AND DATE THE FORM SUPPLIERS NAME AND ADDRESS BLOCK CAPITALS OR PRACTICE STAMP PATIENTS DECLARATION TICK AS APPROPRIATE I E NUMBER OF GLASSES PATIENT OR PATIENTS PARENT CARER OR GUARDIAN PLEASE EN
6. SURE PATIENT PATIENTS REPRESENTATIVE HAS SIGNED AND DATED THE FORM COMPLETE PATIENTS NAME IN BLOCK CAPITALS PCSS Preston INHS England GUIDE TO COMPLETING A GOS 4 FORM THE FOLLOWING IS MANDATORY INFORMATION THAT NEEDS TO BE COMPLETED IN ORDER FOR THE FORM TO BE PROCESSED BY PRIMARY CARE SUPPORT SERVICES PRESTON PLEASE COMPLETE THE FOLLOWING DETAILS IN BLOCK CAPITALS PART 1 PATIENTS DETAILS SURNAME FIRST NAME DATE OF BIRTH FULL ADDRESS WITH POSTCODE DATE OF LAST SIGHT TEST PLEASE TICK RELEVANT PATIENT ENTITLEMENT NAME AND ADDRESS OF SCHOOL COLLEGE UNIVERSITY IF PATIENT IS A STUDENT AGED UP TO 18 IF PATIENT IS NAMED ON A VALID HC2 OR HC3 CERTIFICATE PLEASE PROVIDE NUMBER AND THE VALUE THE VOUCHER WILL BE REDUCED BY FOR HC3 PROVIDE THE NAME OF PRISON IF PATIENT IS A PRISONER ON LEAVE FROM PRISON FULL REASON FOR LOSS DAMAGE IF PATIENT 16 OR OVER PART 2 PATIENTS DECLARATION TICK AS APPROPRIATE I E PATIENT OR PATIENTS PARENT CARER OR GUARDIAN ENSURE FORM IS SIGNED AND DATED BY PATIENT OR PATIENTS REPRESENTATIVE ENSURE PATIENTS NAME IS COMPLETED IN BLOCK CAPITALS PART 3 COMPLETED BY AREA TEAM PCSS PRESTON TICK AS APPROPRIATE AND FILL IN IF APPROVAL IS REQUESTED PCSS Preston INHS England PART 4 PATIENTS DECLARATION TICK IF REPAIR OR REPLACEMENT SERVICE PROVIDED ENSURE FORM IS SIGNED AND DATED PROVIDE DATE AND PATIENTS NAME BLOCK CAPITA
7. stered blind partially sighted 2 years Considered to be at risk of glaucoma 2 years Prescribed Complex Lens 2 years PLEASE TICK RELEVANT PATIENT ENTITLEMENT PCSS Preston NHS England COMPLETE NAME AND FULL ADDRESS OF SCHOOL COLLEGE UNIVERSITY IF PATIENT IS A STUDENT AGED UP TO 18 PARTNERS FULL DETAILS IF PATIENT IS NOT THE ONE RECEIVING BENEFIT HC2 CERTIFICATE NUMBER IF APPLICABLE PROVIDE FULL DETAILS OF THE LOCAL AUTHORITY IF PATIENT IS BLIND PARTIALLY SIGHTED GP IF PATIENT SUFFERS FROM DIABETES GLAUCOMA HOSPITAL IF PATIENT CONSIDERED TO BE AT RISK OF GLAUCOMA BY AN OPHTHALMOLOGIST PRISON IF PATIENT IS A PRISONER ON LEAVE FROM PRISON PATIENTS DECLARATION TICK AS APPROPRIATE I E PATIENT OR PATIENTS PARENT CARER OR GUARDIAN ENSURE FORM IS SIGNED BY PATIENT OR PATIENTS REPRESENTATIVE PROVIDE DATE AND PATIENTS NAME BLOCK CAPITALS PERFORMERS DECLARATION PROVIDE DATE AND OUTCOME OF THE TEST VOUCHER TYPE IF APPLICABLE PERFORMERS SIGNATURE LIST NUMBER AND NAME BLOCK CAPITALS APPROPRIATE CODE IF TEST LESS THAN MINIMUM INTERVAL ADDRESS WHERE SIGHT TEST TOOK PLACE BLOCK CAPITALS OR PRACTICE STAMP ADDRESS WHERE PAYMENT SHOULD BE SENT IF DIFFERENT CONTRACTORS AUTHORISED SIGNATURE CONTRACTORS NAME BLOCK CAPITALS LIST NUMBER AND DATE CONTRACTORS NAME AND ADDRESS BLOCK CAPITALS OR PRACTICE STAMP PCSS Preston INH
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