SCR role for smartcard - request form - Page 1 of 4 - NHS Digital

Application form

1. Your first name:

Name (Required)

2. Your surname:

(Required)

3. Your email address:

(Required)

4. Your smartcard UUID (this is the 12 digits under the photograph):

(Required)

5. Roles requested (tick all that apply):

(Required) SCR Pharmacist SCR Technician SCR Governance Person (SGP)

6. GPhC Registration Number (not required for SGP):

(Required)

If SGP please enter "na".

7. Please enter the ODS code for each pharmacy where access is required e.g. FVP56

Pharmacy 1 (Required)

Pharmacy 2

Pharmacy 3

Pharmacy 4

Pharmacy 5

Note: for a new pharmacy an Acceptable Use Agreement will need to be submitted before RAs can process requests submitted via this form. See section 'Implementing Summary Care Records in community pharmacy'.

8. Do you require access at more than five pharmacies?

(Required) Yes No

9. Do you require locum access? (Only select this option if you intend to work as a locum and already have FFFFF on your smartcard. If you do not, you will need to contact your local RA and provide justification for your requirement, first).

(Required) Yes No

10. If you are applying for the FFFFF locum access please select the name of the CCG where you are likely to work the most.

List of CCG's