Dispensing Doctor Support Service Rebate Scheme: Respiratory 001 50% rebate enquiry form Optimisation of Beclometasone/Formoterol to Luforbec Name of GP Practice: Practice National Code Number of Dispensing Patients: Preferred wholesaler AHH Alliance Account Number Pick Integrated Care System for Activity: (Please check all Integrated Care System regions appropriate to your clinic catchment area) Bath and North East Somerset, Swindon and Wiltshire Bedfordshire, Luton and Milton Keynes Birmingham and Solihull Black Country Bristol, North Somerset and South Gloucestershire Buckinghamshire, Oxfordshire and Berkshire West Cambridgeshire and Peterborough Cheshire and Merseyside Cornwall and the Isles of Scilly Coventry and Warwickshire Derby and Derbyshire Devon Dorset Frimley Gloucestershire Greater Manchester Hampshire and the Isle of Wight Herefordshire and Worcestershire Hertfordshire and West Essex Humber and North Yorkshire Kent and Medway Lancashire and South Cumbria Leicester, Leicestershire and Rutland Lincolnshire Mid and South Essex Norfolk and Waveney North Central London North East and North Cumbria North East London North West London Northamptonshire Nottingham and Nottinghamshire Shropshire, Telford and Wrekin Somerset South East London South West London South Yorkshire Staffordshire and Stoke on Trent Suffolk and North East Essex Surrey Heartlands Sussex West Yorkshire Type of support service(s) needed: Information Only LES Programme for GP Surgeries Managed Patient Engagement Managed Medicines Optimisation Follow Up Service Training for Local Surgery Team Training for PCN Pharmacists Other: Proposed start date: This month Next month Within 3 months Within 6 months Estimate of Number of Patients Needing Optimisation: 0 - 10 10 - 20 20 - 30 30 - 40 > 40 Type of service(s) wanted: Pharmacist without General Practice support Pharmacist with General Practice support General Practice Support Nurse support Trained Healthcare Clinician In order to qualify for your 50% discount please confirm: Please tick all that apply Your pharmacist/respiratory lead will undertake a training session for effective medicines optimisation Patient optimisations will be undertaken to support the ICS medicines cost optimisation programme You are aware that Lupin are providing a carbon offset programme to support this service Request for activation of this QIPP enhanced discount rate: Key Contact 1 - Administration Lead First Name Last Name Tel: Email Key Contact 2 - Clinical Lead First Name Last Name Tel: Email Thank you!
