Smartcard Access Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please use this form if you have a NHS smartcard already issued in your name but and are unable to get a sponsor to complete a request via Care Identity Service (CIS) portal.

1. Full Name (please give your GPHC registered name) *

2. Confirm that you live in Bolton *

If you live in other areas of Greater Manchester please complete the form on the GM LPC website https://psnc.org.uk/greater-manchester-lpc/resources/smartcard-access/. If you live outside of Greater Manchester you will need to contact the local RA in the area that you live in. Details can be obtained here: http://bitly.ws/6cXT

Yes

3. Home Postcode - to match documents on ID check appointment: *

4. Preferred contact telephone number *

5. Email address *

6. Smartcard Number *

7. GPHC number *

8. Do you need Locum (FFFFF code) assigned? *

Yes

9. If no, please provide F code: *

10. Do you need SCR access? *

If Yes, please ensure you have completed the SCR e-assessment and given access to the RA to view completion

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms