Npl 2: National performers lists change notification form: Movement to a different area team Notes for completion



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NPL 2: National performers lists change notification form: Movement to a different area team

Notes for completion

A performer is required to notify NHS England of any change requiring amendment to the information recorded in a performer list as set out Regulation 19 (1) in the National Health Service (Performers Lists) (England) Regulations 2013. The notification must be given within 28 days of the change unless it is impractical for the performer to do so. Changes include any change of registered address, practice or the status of inclusion in the list.

This form should not be used by contractor holders to notify area teams about any contractual changes

Where performers move between area teams a performer is required to complete the relevant section of this national performers lists change notification form to enable the performer to be assigned to a new responsible officer/medical director and to transfer appropriate information in line with NHS England’s information governance arrangements. NHS England’s confidentiality and information governance policies can be found at http://www.england.nhs.uk/about/policies/



Medical performers should complete Section 1 only

Dental performers should complete Section 2 only

Ophthalmic performers should complete Section 3 only
Forms should be sent to the area team in which the performer will be working. Details can be found at:

http://www.performer.england.nhs.uk/AT/SearchByPostcode
Section 1
National medical performers list – transfer to a new area team
Surname:
Forenames:
GMC number: 
Date of birth:  /  /  Gender:  Male  Female
Nationality:
Home address:

Postcode
Contact telephone no:

Email address:


Do you wish your earnings to be superannuable?  Yes – NI number  No
Is the above address your registered GMC address:  Yes  No*
*If no, please state your registered GMC address:

Postcode
Date of last appraisal  /  / 
Proposed date of next revalidation with the GMC, if known:  /  / 
New or current post/working details:


Please tick as appropriate:

New Practice details

 GP Performer

Practice name and address:

Practice code:


Start date:

 Salaried GP by Practice

 Salaried GP by CCG

 GP Registrar

 Retainer

 Returner

 Locum

If you intend to work as a locum – in which area(s) do you intend to do the majority of your locum work?

Continued overleaf …



Previous post/working details:


Please tick as appropriate:

Last practice details

 GP Performer

Practice name:

Practice address:


End date:



 Salaried GP by Practice

 Salaried GP by CCG

 GP Registrar

 Retainer

 Returner

 Locum

Which NHS England area team are you currently aligned to?




North

Cheshire, Warrington and Wirral

 Cumbria, Northumberland, Tyne and Wear

 Durham, Darlington and Tees

 Greater Manchester

 Lancashire

 Merseyside

 North Yorkshire and Humber

 South Yorkshire and Bassetlaw

 West Yorkshire

Midlands and East

Arden, Herefordshire and Worcestershire

 Birmingham, Solihull and the Black Country

 Derbyshire and Nottinghamshire

 East Anglia

 Essex

 Hertfordshire and the South Midlands



 Leicestershire and Lincolnshire

 Shropshire and Staffordshire



London

North East London

 North West London

 South London

South

Bath, Gloucestershire, Swindon and Wiltshire

 Bristol, North Somerset, Somerset and


South Gloucestershire

 Devon, Cornwall and the Isles of Scilly

 Kent and Medway

 Surrey and Sussex

 Thames Valley

 Wessex


Are you currently included in NHS England’s medical performers list subject to

conditions?  No  Yes*
Are you currently subject to GMC conditions or undertakings?  No  Yes*
Are you currently the subject of any investigation by any regulatory

or other body?  No  Yes*


Are you currently the subject of any investigation in respect of any

current or previous employment?  No  Yes*


*If you have answered yes to any of the four questions above, please give details on a separate sheet.
Signature Date
Name
Please return to:
Address
Tel: XXX / Fax: XXX /
Email:


Section 2

National dental performers list – transfer to a new area team
Surname:
Forenames:
GDC Number: 
Date of Birth:  /  /  Gender:  Male  Female
Nationality:
Home address:

Postcode
Contact telephone no:

Email address:


Is the above address your registered GDC address:  Yes  No*
*If no, please state your registered GDC address:

Postcode
Performer number from POL, if known:  /  / 
New or current post/working details:


Please tick as appropriate:

New practice details

 Performer

Practice name:
Practice address:

Contract number:


Start date:

 Provider & performer

 Dental trainee

 Community dental service dentist

 Prison dentist

 Locum

If you intend to work as a locum – in which area(s) do you intend to do the majority of your locum work?

Continued overleaf …



Previous post/working details:


Please tick as appropriate:

Last practice details

 Dental Performer

Practice Name:

Practice Address:


End date:



 Provider & performer

 Dental trainee/Foundation Dentist

 Community dental service dentist

 Prison dentist

 Locum

Which NHS England area team are you currently aligned to?




North

Cheshire, Warrington and Wirral

 Cumbria, Northumberland, Tyne and Wear

 Durham, Darlington and Tees

 Greater Manchester

 Lancashire

 Merseyside

 North Yorkshire and Humber

 South Yorkshire and Bassetlaw

 West Yorkshire

Midlands and East

Arden, Herefordshire and Worcestershire

 Birmingham, Solihull and the Black Country

 Derbyshire and Nottinghamshire

 East Anglia

 Essex

 Hertfordshire and the South Midlands



 Leicestershire and Lincolnshire

 Shropshire and Staffordshire



London

North East London

 North West London

 South London

South

Bath, Gloucestershire, Swindon and Wiltshire

 Bristol, North Somerset, Somerset and


South Gloucestershire

 Devon, Cornwall and the Isles of Scilly

 Kent and Medway

 Surrey and Sussex

 Thames Valley

 Wessex


Are you currently included in NHS England’s dental performers list subject to

conditions?  No  Yes*
Are you currently subject to GDC conditions or undertakings?  No  Yes*
Are you currently the subject of any investigation by any regulatory

or other body?  No  Yes*


Are you currently the subject of any investigation in respect of any

current or previous employment?  No  Yes*


*If you have answered yes to any of the four questions above, please give details on a separate sheet.
Signature Date
Name
Please return to:
Address
Tel: XXX / Fax: XXX /
Email:


Section 3
National ophthalmic performers list – transfer to a new area team
Surname:
Forenames:
Whether:  Optometrist  Ophthalmic medical practitioner (OMP)
GOC or GMC Number: 
If OMP – state Ophthalmic Qualifications Committee number
Date of birth:  /  /  Gender:  Male  Female
Nationality:
Home address:

Postcode
Contact telephone no:
Email address:
Is the above address your registered GOC/GMC address:  Yes  No*
*If no, please state your registered GOC/GMC address:

Postcode
Date of last appraisal (OMP only):  /  / 
Proposed date of next revalidation with the GMC, if known (OMP only) /  / 
New or current post/working details:


Please tick as appropriate:

New Practice details

 Optometric performer


Practice name:

Practice address:


Start date:



 Ophthalmic medical practitioner

 Locum

If you intend to work as a locum – in which area(s) do you intend to do the majority of your locum work?

Continued overleaf …



Previous post/working details:


Please tick as appropriate:

Last practice details

 Ophthalmic performer


Practice name:

Practice Address:


End date:



 Ophthalmic medical practitioner

 Locum

Which NHS England area team are you currently aligned to?




North

Cheshire, Warrington and Wirral

 Cumbria, Northumberland, Tyne and Wear

 Durham, Darlington and Tees

 Greater Manchester

 Lancashire

 Merseyside

 North Yorkshire and Humber

 South Yorkshire and Bassetlaw

 West Yorkshire

Midlands and East

Arden, Herefordshire and Worcestershire

 Birmingham, Solihull and the Black Country

 Derbyshire and Nottinghamshire

 East Anglia

 Essex

 Hertfordshire and the South Midlands



 Leicestershire and Lincolnshire

 Shropshire and Staffordshire



London

North East London

 North West London

 South London

South

Bath, Gloucestershire, Swindon and Wiltshire

 Bristol, North Somerset, Somerset and


South Gloucestershire

 Devon, Cornwall and the Isles of Scilly

 Kent and Medway

 Surrey and Sussex

 Thames Valley

 Wessex


Are you currently included in NHS England’s ophthalmic performers list subject to

conditions?  No  Yes*
Are you currently subject to GOC or GMC conditions or undertakings?  No  Yes*
Are you currently the subject of any investigation by any regulatory

or other body?  No  Yes*


Are you currently the subject of any investigation in respect of any

current or previous employment?  No  Yes*


*If you have answered yes to any of the four questions above, please give details on a separate sheet.
Signature Date
Name
Please return to:
Address:
Tel: XXX / Fax: XXX/


Email:





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