The Income Team,
Room 11
Finance Dept
Manor House Annexe
From:
Audiology Department
Level LG1, West Wing
John Radcliffe Hospital,
Headley Way
Oxford OX3 9DU
Tel: 01865 234585
Fax: 01865 231206
Email: audiology.department@ouh.nhs.uk
#Current date (long format)#
#Client last name#,
#Client
firstname#
name#
#Appointment
resource
user full
#Client address#
#Client
postcode#
#Appointment
resource user title#
Hospital no: #Client primary identification code#
I agree to pay to the Oxford University Hospitals NHS Foundation Trust the sum of
£110 / £220 relating to the loss of / damage to my NHS Cochlear Implant(s).
Signed:
Date:
Cost Centre A68680
Subjective code 474100