Smart Card / RA form

Please ensure that all information provided on this form is accurate. Inaccuracies will cause delays in your request being processed.

Guidance on Care Identity Management usage for all smartcard users

Did you know you are able to setup self service unlocks for your smartcard? https://digital.nhs.uk/services/registration-authorities-and-smartcards/self-renewal-nhs-smartcard-service

Consent

RA Agent

If you work in a GP practice or pharmacy, your site should have an RA sponsor and agent who will be able to complete various RA tasks for you. Please contact them first before completing this form. If you are the RA sponsor or agent for this site, please continue with the form.

By completing this form you consent to us storing the data *

Yes, I give permission to store and process my data

My details

Your first name *

Your surname *

The name you are known by (if different to above)

Your email address *

Email is the primary way we will contact you, so ideally provide a work email address in your name. Avoid shared email addresses as we are unable to provide PIN codes to a shared account

Your contact number *

This can be a work or personal number, whichever is the best number to contact you on if we need more information.

Your job title *

Are you logging this request on behalf of someone else? *

Request is for myself

Logging the request on behalf of someone else

User details

Their first name *

Their surname *

The name they are known by (if different to above)

Their email address *

Email is the primary way we will contact the user, so ideally provide a work email address in your name. Avoid shared email addresses as we are unable to provide PIN codes to a shared account

Their job title *

Workplace

RA helper

If your organisation is not in the list visit https://digital.nhs.uk/services/registration-authorities-and-smartcards/primary-care-service-provider-contact-details to check who provides your RA support

Name of the company that you/the user work for *

What is your location/site name? *

Are you a locum? *

Yes

ODS Code or NACS Code for the site you/the user works at *

If you are a Community Pharmacist locum please enter 'N/A'

ODS helper

You can find your ODS/NACS using https://odsportal.digital.nhs.uk/Organisation/Search

What department and team do you/the user work in? *

What location are you/the user based at? *

Register

Which smartcard do you require *

Physical smartcard

Virtual smartcard (only available if your organisation is signed up to this)

Has the site agent/ID checker already registered you/the user on the CIS Portal?

Yes

GPHC Registration Number

If applicable

Title *

Middle name

If applicable

Occupation

Change access or site

For Summary Care Records access please email scrpharmacy@nhs.net

What is required *

What access should be removed? *

Provide the position code, if applicable

What access should be added? *

Provide the position code, if applicable

What access is required? *

What sites should access be added/removed for? *

What position is required? *

Provide the access code if known

Unlock/renew smartcard

We are unable to unlock physical smartcards remotely

What date do the certificates expire? *

Replacement

Provide a reason for damage *

UUID / Smartcard number from CIS Portal *

If applicable

Postal address

If applicable

Use this box to add any supporting notes *

If applicable