Electricity Reimbursement Form

1Instructions
2Patient Details (Section A)
3Payment type (Section B)
4Comments and submit (Section C)

HOW TO FILL OUT THE FORM

In Section A, please fill out all boxes with the patient’s details.

All patients need to tell us the name of their electricity provider in Section B. We need to know your supplier’s name so that we can calculate your refund correctly and ensure you are added to their priority service register.

Now you need to decide how you wish to receive your refund:

BACS TRANSFER

You can be paid directly into your bank account – this is the quickest and most secure method, clearing within five working days of issue.

PERSONAL CHEQUE

You can receive a cheque to your home address (which can be issued in your or another name authorised by you), normally arriving within two weeks of issue by us.

ELECTRICITY SUPPLIER DIRECT PAYMENT

We can pay your electricity supplier direct, and they credit your domestic electricity bill. While we allocate your reimbursement to the relevant electricity supplier within three to five working days of our routine payment runs, we have noticed that patients who have selected this method often wait for up to three months before these monies are credited by their supplier.

    Re-Ordering Oxygen Cylinders, Liquid Oxygen or Consumables

    To request replacement oxygen cylinders, nasal prongs, mask or consumables, please complete the form below. Please note that orders received after 6.30pm will be processed the next day:

    Do you or anyone in your household have cold or flu symptoms?


    If you are requesting a cylinder delivery you can chose a day for your delivery.

    Monday-Friday for North West patients or seven days a week in other areas.


    Please let us know your requirements:

    Large Static Cylinder

    Large static cylinder
    Used in the home, often for babies and children, Cluster Headache diagnosis or emergency oxygen

    Portable Cylinder

    Portable cylinder
    Used to move around inside/outside of the home

    Small Portable Cylinder

    Small portable cylinder
    Only available after a professional medical assessment

    Liquid Oxygen Tank

    Liquid oxygen tank

    Adult Cannula (Curved)
    Adult Cannula (Straight)
    Adult Mask
    Ear Protectors
    Paediatric Cannula
    Paediatric Mask
    Filter for Oxygen Machine
    Tender Grips

    Any other comments


    *required fields

      How can we help you?

      Please use the area below to submit your enquiry. It will then be passed on to the relevant contact person for a response.

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