To: The Manager
Patient Data
Avon Primary Care Support Agency
Date:…………………..…
Name of patient/s: …………………………………………DoB or NHS No.………………………….
Name of patient/s: …………………………………………DoB or NHS No.………………………….
Name of patient/s: …….………………………………… DoB or NHS No…………………………..
Name of patient/s: …………………………………………DoB or NHS No.………………………….
Name of patient/s: …….………………………………… DoB or NHS No…………………………..
Address: …….………………………………………………………………………………………………
…………………………………………………………………………………………………….
Please remove the above-named patient/s from this practice’s list with 7 days notice.
I understand that this type of removal is only appropriate in certain circumstances such
as a breakdown in doctor/patient relationship, failure to keep a number of appointments
or when an address outside our boundary was notified to us more than 30 days ago.
Yours faithfully
GP partner’s signature: ……………………………………….
GP partner’s name:
…………………………………………
GP practice name and address: ……………………………………………………….
……………………………………………………….
.……………………………………………………….
……………………………………… ……………….
NB Please complete both sections of the form overleaf.
Please fax this form to the Patient Data team on 0117 900 2401 or email it from an NHS
Mail account to avonlinks@nhs.net
April 2013
Page 2
ACTION LIST FOR REMOVING A PATIENT AS A DOCTORS’ REQUEST
Please complete both sections a) and b) below:
a) Removal Warning (must be completed)
1.
A warning was issued in the previous 12 months to the above patient/s
to explain that they were at risk of being removed from the practice
list and giving the reasons why (Part 2, para. 20 (3)).
Yes
No
a) Date warning given to patient…………………………………………
b) Reason given for warning…………………………………………………
………………………………………………………………………………
……………………………………………………………………………..
2.
If No, please give the reason below (tick relevant box)

It is not reasonably practical to do so

It would be harmful to the physical or mental
health of the patient/s

It would put the safety of the contractor or another
person at risk
Please note that a record must be kept of the above and made available to the Area Team
on request.
b) Removal Request (must be completed)
1.
The above patient/s has been notified of their removal from
the list and given the reason.
Yes
No
a) Reason given for removal…………………………………….
…………………………………………………………………..
…………………………………………………………………..
2.
If the answer is No, please give the reason below:

It is not reasonably practical to do so

It would be harmful to the physical or mental
health of the patient/s

It would put the safety of the contractor or another
person at risk
Please note that a record must be kept of the above and made available to the Area Team
on request.
April 2013