Website of the Department of Health

Revised hospital out-patient forms HSA5 (supply of drugs or elastic hosiery) and WF1 (supply of wigs or fabric supports) are available below. These are based on the updated "0403" version of the FP10 prescription form (updated for the introduction of Pension Credit in October 2003).

The HSA5 should be used to obtain a patient declaration regarding their liability to pay prescription charges when an "FP10" type prescription has not been issued by the prescriber. The WF1 should be used when a wig or fabric support is prescribed for an out-patient. Please print out these forms and reproduce each locally, ensuring that patients have the opportunity to read the advice notes. You may wish to produce the forms as two pages stapled together or as a one page "backed" i.e. double sided document.

Guidance on exemption or prescription prepayment certificates

Medical / maternity exemption certificates or prescription prepayment certificates exempt patients from prescription charges which include charges for elastic hosiery. However, an HC3 (partial help NHS Low Income Scheme certificate) does not apply to elastic hosiery.

An HC3 is valid for help with charges for wigs and fabric supports but medical / maternity exemption certificates or prescription prepayment certificates are not.

• Download NHS Form HSA5 - Supply of drugs and elastic hosiery to NHS hospital outpatients: updated July 2007 (PDF, 165K)
• Download NHS Form WF1 - Supply of wigs and fabric supports to NHS hospital outpatients: updated July 2007 (PDF, 167K)
• Forms HSA5 and WF1 (Welsh Goverment website) (opens new window)