Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your provider name, address, and contract number in the designated fields. Ensure all details are accurate to avoid any delays.
3. Input your email address in the appropriate field to facilitate communication regarding your application.
4. Provide details about any other addresses associated with your contract if applicable. This information may be necessary for your application.
5. Indicate whether you are solely responsible for the payment of the demand by selecting 'Yes' or 'No'. If 'No', list the names of all parties responsible along with the percentage of the bill they account for.
6. Enter your contract number, along with the percentage of the bill that is applicable for each responsible party.
7. If applicable, indicate whether Small Business Rate Relief has been claimed for this property. If it has not, provide the reason in the specified field.
8. Submit details regarding the property, including the rateable value and the NHS percentage of income derived from NHS treatments.
9. Specify the total reimbursement amount requested and choose how this bill will be paid, selecting either a one lump sum, first half-year, second half-year, or monthly installments.
10. In the supporting documents section, ensure you include evidence showing the NHS proportion claimed in the previous financial year, a copy of the demand notice, and relevant receipts, keeping in mind not to submit original documents.
11. Finally, complete the provider's declaration by confirming that there is no reimbursement for business rates included within the contract payment. Sign and date the form, and if applicable, print your name if you are signing on behalf of a corporate body.

Complete your documents online to ensure a smooth application process.