| Appendix D:
Model Undertaking to Pay |
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| Model Undertaking to Pay Form for NHS
charges for treatment for Overseas Visitors. This Appendix should be read and completed in
conjunction with Chapter 7 (NHSiS: Overseas Visitors, Financial Control) of this Manual. |
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| 1. Section 1: This Section is
to be completed in all cases in which an Undertaking to Pay is required. |
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Patient’s Name:
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Patient’s Date of Birth &/or hospital number:
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Patient’s UK address:
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Patient’s (planned) date of departure
from UK:
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| 2. Section 2: This Section to
be completed, in addition to Section 1, if the person (sponsor) signing the Undertaking to
Pay Form is not the patient. Note: In cases where the
patient is unable to sign the undertaking and a third party decides to take
on the role of 'sponsor', and agrees to sign the form to assume the responsibility to meet
the NHS charges for the treatment required, it should be made clear to that person (the
sponsor) that the NHS charges fall to them (the sponsor) to pay and not the
patient. It is for them (the sponsor) to resolve any subsequent reimbursement of their
financial undertaking with the patient. |
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Name of person accepting the undertaking to
pay on the patient’s
behalf:
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UK address:
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Date of (planned) departure from UK (if
appropriate):
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Non-UK address:
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Relationship to patient:
.............................................................................
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| 3. Section 3: Declaration
(by Sponsor) |
| I undertake to pay the ......................
Health Board or NHS Trust such sums as may be due to them in terms of the NHS (Charges to
Overseas Visitors) (Scotland) Regulations 1989, as currently in force for the treatment
provided to .................................(Patient’s name) on and
after...........................................................(date(s)). |
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Treatment Date
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Treatment Date
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Treatment Date
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Continuing/ended (delete, whichever appropriate)
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| Signed
………………………….(patient/sponsor) Date: Print
name:..........................................(patient/sponsor) |
| Note: NHS charges cannot
be waived for treatment of overseas visitors where they are due. Wherever possible, full
payment should be obtained in advance for NHS treatment. |
