Reporting template

DO NOT USE THIS FORM

It is currently for testing only

Hertfordshire and West Essex ICB Provider Query: Reporting Template  

Date completing form

Provider Reporting Query

PCN (for GP practices)

Name of person completing form

First Last

Phone

If you would like us to follow up your query in relation to a particular patient it is essential that you give us the following information

Patient's name

First Last

Patient's date of birth

Patient's NHS number

Please indicate the outcome you expect from this report

If you selected Other, please give more information

Which provider does this concern relate to?

Which speciality/GP does this relate to?

Please give details of the issue you are raising providing as much detail as possible(Required)

Will you need to send over some supporting documents or files as part of this?(Required)

You cannot attach documents to this form. If you check Yes, we will email you to request these – please do not send anything until asked. If you select Yes, your query will not be processed until these have been sent.

Yes – I will need to send some attached documents

No – all of the information I need to give is included in this form

Please indicate if the patient came to harm as a result of this issue

Please give details about the actions the provider has already taken in relation to this issue

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DO NOT USE THIS FORM

Hertfordshire and West Essex ICB Provider Query: Reporting Template

Hertfordshire and West Essex ICB Provider Query: Reporting Template  