Application Form for Continuing HealthcareAssessment

CONSENTFORM

Part1:User Notes

Important –pleaseread theseusernotesbefore you sign theconsent

Beforewecanundertake thecontinuinghealthcareassessmentyouhave requested, we requireyourconsenttoaccesshealthandsocial carerecords.Ifyouarenotthepatient,we also need toestablish thatyou have theauthoritytoactonthepatient’sbehalf.

Anyone can request that they (a patient) have a Continuing Healthcare assessment, however,incaseswherethepatientdoesnothavethementalcapacity to managetheirownaffairs,therequestmustbeaccompaniedby copiesoflegally accepted documentation in orderforthe caseto proceedtoinvestigation.

Why dowe need consent?

The Commonlaw dutyofConfidentiality

The commonlaw,caselawdetermined bythe Courts,hasestablished that information provided by individualsin confidenceshould generallybe protected andnotdisclosedto anyone other thanthepersontowhom the informationwas provided orused forother purposeswithout their consent. The dutyofconfidentialityowed byclinicians totheir patients is well established and isin additiontotherequirementsof the Data Protection Act 1998 and other legislative requirements.

In signing the consentform you areconsentingtotheassessmentteam seekinginformation from the NHS andother organisations orindividuals,asappropriate, specificallyand solely with regardtothisassessment

Ifyou areconfirmingthat ifyou arenot the patient thisclaimrelatesto,youshouldhavesomeform oflawful authorityto act onthe patient’sbehalf.

Keylegislation governing accesstopersonal datacomprises

DataProtectionAct1998 / Governsaccesstothe personal data held in records pertaining toliving
people.
Access to HealthRecordsAct1990 / Governsaccesstothe personal data
pertaining todeceasedpeople

Legally accepted documentationfor living patients

  • The holderofEnduring PowerorAttorneyregistered with the Court ofProtection.
  • A receiverappointedbythe Public GuardianshipOffice of the Court ofProtection.
  • A Personappointedbythe Court ofProtection
  • A personholdingLasting PowerofAttorneyregisteredwith theoffice of the Public Guardian.
  • Ifnone of the above,hasa bestinterestsdecision beenmade?

Fordeceased patients

  • TheholderofaGrantof Probateor GrantofLettersofAdministration

orconfirmationthe applicantis in theprocess of obtainingauthorityfrom the Probate

Registry(which will be requiredbeforetheclaimcan be considered)

  • A redacted copyof theWill showing the Executor /Administratoror beneficiary
  • Legal evidence thataWill isbeing contested

Please note‘NextofKin’ status doesnot give you accessthepatientspersonal datarecords and withoutappropriateauthorisation yourclaim cannotproceedtoinvestigation.

Proofof identity.

Please note you will be requiredtoprovide proofofidentity.Certified copies ofat least two itemsofevidencelistedbelowmustbeprovided;with at least one of those being fromtheprimaryevidence list. Youmayifyou wish bring theoriginal document tothe addressonthe letterand theassessment teamwill photocopythemforyou.

Primarydocuments forproof ofidentity:

UK passport /other countrypassport

DrivingLicence

Adoption certificate

Separation document

Annulmentdocument

AliensRegistration Certificate

IND SAL letteror travel document

National ID card

NINO cardwith National InsuranceNumber

National Insurance contributions form

Medical cardwith NHS number

HMforcesemploymentcertificate

Change ofnamedocument

Statebenefit Book/Notification letter

Sub-contractorscertificate

P45

E111

Secondarydocumentsforproofofidentity

Payslip

Tenancyagreement, rentbookorrentcard

Utilitybillssuch asgas,electricityand water

Fixed telephone bills

Railcard,travelcardandbus-pass

Season ticket.

Bankor BuildingSocietydebitorcreditcards

Storechargecard

Bankorbuildingsocietystatement/passbook

Shares certificates

Lifeinsurancepolicy

Trade Unionmembership card

Part2:Consent form

Please completeandreturnthispartof theform, togetherwith appropriatedocumentationas listed.

PATIENT’S NAME …………………………………………………………..

Ifyou arethe patient –pleasecompletesection A

Ifyou arenot thepatient –please completesection B

SECTIONA: Forcompletion bythe patient:

I, theundersignedconsent to allowanyone involved in theContinuingHealthcarereview processtohave access to all relevanthealthandsocial carerecords,which mayinclude medical details, in order togatherall information necessarytoassessormyeligibilityfor NHS ContinuingHealthcare.
Nameof representative………………………………………......
Signed……………………………. Date……………………………
______
I agreethat the evidence presentedtothe CCGorIndependent ReviewPanel maybe shared with myrepresentative namedabove.
Signed……………………………Date…………………………………..
SECTION B: Forcompletion bythe patient’s representative if thepatient isincapable ofcompletingSectionAwhich hasbeen assessed inaccordancewith theMental CapacityAct2005.
I, theundersignedconsent to allowanyone involved in theContinuingHealthcarereview processtohave access to all relevanthealthandsocial carerecords,which mayinclude medical details, in order togatherall information necessarytoassessormyeligibilityfor NHS ContinuingHealthcare.
Nameof representative…………………………………………………......
Signed……………………………. Date……………………………
SECTION C: Forcompletion bythe patient’s representative if thepatient isdeceased.
Are you thepersonalrepresentative ofthe deceased patient?YESNO
You mustprovidethe appropriate original documentationofproof toactonbehalfof the deceasedasfollows:-
Aredacted copyof theWillshowingthe Executor/Administratoror beneficiary
Asealed GrantofProbateorGrantofLettersofAdministration orconfirmation the applicant isinthe process ofobtaining authorityfromtheProbate Registry(which will be requiredbeforethe claimcanbeconsideredfully).
Legalevidencethat a Will isbeingcontested
(You mustprovide twoproofs of identity(seeusernotes))
Please seelistofdocumentsprovidedonthenextpage
Onthe patient’sbehalf I therefore consent toallowanyone involved in the Continuing Healthcarereviewprocess tohave accesstothepatient’srelevantrecords,which may include medical details, in order togather all thenecessaryinformation tocompletethe continuing healthcareassessment requestedbyme.
Signed……………………………………. Date……………………………………..