Healthpay Staff Form
Please fill out the form accurately. Fields marked * are required and must be completed.
What type of form are you sending?
*
Please Select
Joiner
Leaver
Amendment
Pension opt-in
NHS Pension opt-out
Please note that non NHS pension employees can only opt out by contacting the pension provider
Please indicate your permission to send you a copy of this form
*
Yes
No
Your Company Name
*
Your Name
*
Your Email Address
*
example@example.com
Employee Name
*
First Name
Last Name
Gender
*
Male
Female
DOB
-
Day
-
Month
Year
Date
National Insurance Number. If you do not have an NI number please leave it blank, but ensure that you let us know the NI number as soon as you have it.
Two letters, 6 numbers and a letter
Employee Address
Employee Post Code
Employee Email Address
example@example.com
Employee passport number (if available)
Client Type
Please Select
NHS
Non-NHS
NHS or non NHS
Extra Information for NHS Clients (please note that GPs cannot be enrolled or opted-in by us. Refer to PCSE)
Please Select
Employee
GP
Apprentice
Zero hours staff
Employee or GP
Hourly Rate
*
Hourly rate in pounds and pence
Weekly Hours
*
Please use hours and decimals eg 25.25
Whole Time Hours
*
Session Rate
Please input rate in £ and pence
Weekly Sessions
Pension Rate
Employed as
Job description
Department
Start Date
-
Day
-
Month
Year
Date
Apprenticeship end date
-
Day
-
Month
Year
Date
Leaver or NHS pension opt-out date
*
-
Day
-
Month
Year
Date
Do you have a form RF12 from the employee requesting a refund of pension contributions? Please note that, if the request to opt out is within a month of enrolment we are able to refund the contributions via the payroll and no further information is required. Otherwise please ensure the next five fields are filled in.
No
Yes
Name and address of bank for payment of refund
Name of account holder
Bank sort code
Account number
Building society reference
Holiday Fund
Does your employee have a P45?
*
Yes
No
P45 leaving date
-
Day
-
Month
Year
Date
P45 Tax Code
eg 1257L
Does the P45 tax code have an X indicating that it is a week 1/month 1 tax code?
Yes
No
Week/Month
The week or month number of the last payment, if present
Pay to Date
Tax to Date
Starter Checklist
*
A) This is my first job this tax year
B) I have had another job this tax year
C) I have another job
Student Loan
Please Select
Yes
No
Confirm Loan Plans
Plan 1
Plan 2
Plan 4
Plan 5
Post Grad Loan
Please Select
Yes
No
Bank Sort Code
Bank account no
Building Soc Reference
Comments
Submit Form
Form validity
P45/Update MS
-
Day
-
Month
Year
Date
NHS Pensions
-
Day
-
Month
Year
Date
Audit
-
Day
-
Month
Year
Date
Monitor
Please Select
No
Yes
Should be Empty: