Registration Form

Before You Complete the Form

Please read the below instructions before completing the form.

You will need the following information in hand before you complete the form. The information you enter may be used depending on the options you select for your recognition with certain insurers.

When completing the form, please ensure you do not navigate away from the form. You must complete the form in one session, as you will be unable to save and complete at a later date or time. The form will take approximately 20 to 30 minutes to complete.

You must have the following information to hand before you start completing the form. All mandatory fields are marked with an asterisk (*). For help with the form please contact Customer Services on 0330 900 4900.

  • Where applicable details about your current NHS post
  • Where applicable confirmation of your NHS Post, a named referee and an NHS reference. If you do not have a suitable reference you may download a template reference here. Please note: NHS references and evidence of practice is required for:
      • Other professions may omit this section. Practitioners who gained their experience within the military may submit their ASV/AB certification.
  • Details of your private practice including the name and address of the facilities you use
  • Your specialty and the procedures/ treatment you carry out
  • Details of any qualifications you have obtained
  • Details of any certificates you have achieved including a scanned copy of the certificate
  • Bank details for receiving insurer payments
  • Details of your medical indemnity including a scanned copy of the certificate

As part of your application, you are required to upload a scanned copy of the following documents:

  • NHS reference required for the above listed professions
  • Any professional certificates you have obtained
  • Medical Indemnity

Any files you wish to upload must either be in PDF, PNG, JPEG or GIF format and must not exceed 5MB.

Proceed
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custserv@healthcode.co.uk
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Fitness to Practice information
Practising privileges withdrawn (historic) and details
Prior or current investigations and proceedings by the police and any professional body, both UK and non-UK and details
Disclosure barring certificate
By ticking the box, you give consent to Healthcode to process the information for the above-mentioned purposes. The information may be shared with for the performance of providing the product and service and of any contract Healthcode enter into with them or you.
You can withdraw your consent at any time. However, this will not affect the lawfulness of any processing carried out before you withdraw your consent. If you withdraw your consent, we may not be able to provide all the services related to The Private Practice Register to you.