GP Individual Funding Request Application Form 2013/14 (December)

GP Application form for Procedures of Limited Clinical Value/Effectiveness (POLCV/E) Prior Approval and Individual Funding Request (IFR)

2013/14

IMPORTANT

Before completing this application form, it is essential that you are aware of the eligibility criteria for the treatment requested. Please refer to the following policies to confirm whether the treatment you are requesting requires prior approval, and if so what specific information is needed in order for a funding decision to be made:

  • For patients registered with GPs in Waltham Forest, Newham, City and Hackney and Tower Hamlets please refer to the WELC Procedures of Limited Clinical Value (POLCV) policy.
  • For patients registered with GPs in Barking and Dagenham, Havering and Redbridge please refer to the BHR Procedures of Limited Clinical Value (POLCV) policy.
  • For patients registered with GPs in Barnet, Camden, Enfield, Haringey or Islington please refer to the NCL Procedures of Limited Clinical Effectiveness (POLCE) policy.

These publications and the Clinical Commissioning Group (CCG) IFR policy should be available on your CCG website, and should inform completion of this form. Please contact the IFR Team on 020 3688 1290 if you have any queries, or if you require help completing this form.

Information Governance Statement
All Individual Funding Requests (IFR) may be reviewed by the Clinical Commissioning Group (CCG) as the statutory body responsible for funding decisions. This application form and any other supporting information supplied may therefore be shared with the CCG or other trusted organisations legitimately acting on behalf of the CCG. Personal information may be retained only for the purposes of this IFR and, in some cases, may be used for invoicing and payment reconciliation. Anonymised information may also be shared as part of CCG reporting processes.
PLEASE SIGN OR TICK BELOW TO INDICATE THAT YOU:
1. Have discussed the Information Governance Statement with your patient and that they give their consent for information about their case to be used to process their application in accordance with the provisions of that statement.
2. Will take full responsibility for informing the patient about the IFR process including informing them of the funding decision and their right of Appeal (if necessary).
Please tick 
Applicant’s signature
Signed by: ……………………………………………..…….. Date signed: ….……/…..……/..…….
Print name: …………………………………………………..
All forms must be signed by the NHS Practitioner (unsigned forms will not be accepted)
  • Please ensure all relevant boxes are complete. Incomplete forms will be returned.

Procedure requested:
Indication:

Contact Information:

Date of application
  1. Applicant details
/ Name
Designation
Tel
Email – please provide secure nhs.net address for all related correspondence / NOTE: only nhs.net addresses are acceptable for confidentiality reasons
GP Practice
GP Practice postcode
GP Practice code
CCG
  1. Patient details
/ Patient initials:
Patient NHS Number:
DoB:
Male / Female
  1. Referral Details
Please give details of the organisation that will provide the requested treatment. / Speciality referred to:
Name & address of Clinician & provider referred to:

NOTE: Please read carefully the next sections on how to proceed with your funding application as incomplete information will delay the decision process.

Please do not include any patient identifiable data from this point forward in the application (Name, initials, DoB, age, gender etc.)

Instructions:

Section A should be used for POLCV/E Prior approval applications where the patient meets the eligibility criteria outlined in the corresponding policy.

Section B should be used for IFR applications, including applications for POLCV/E listed treatments where the patient does not meet the eligibility criteria.

SECTION A POLCV/E Applications ONLY

Category of intervention
Referring to the POLCV/E policy please state which POLCV/E treatment the application is for (e.g. Breast reduction, scar revision,abdominoplasty etc.) / Reading from the POLCV/E policy, please state how the patient meets all the relevant inclusion criteria for the requested treatment?
Please use standardised scores and measures as far as possible e.g.
3cm rather than “large”;
BMI 35 rather than “overweight”
A Visual Analogue Scale score rather than “lot of pain” etc.
Additional Information
Please describe any other relevant clinical factors which might support this application.
Please attach all relevant information e.g. referral letters from other clinicians etc.

Section B – IFR Applications and POLCV/E applications where patient does not meet eligibility criteria

Previous treatment history
(e.g. please list standard treatments the patient has already received for this condition)
Any other relevant co-morbidities
Preferred Provider
(Is there a local NHS provider?)
Costof treatment if known
Clinical Effectiveness
Please indicate how strong you think the published evidence base is for this intervention for this condition / Strong / Medium / Weak / Don’t Know
Exceptionality
How many patients with this condition would you expect an average GP practice to see each year?
Exceptionality
Please describe any relevant clinical factors which make this patient’s case exceptional.
Please address the following questions.
How is this patient is:
  1. Clinically different to the general population of other patients with the same condition?
  1. Likely to gain a significantly greater health benefit from the intervention than might be expected for the average patient with the condition?

Impact of condition/ treatment
Please describe how this condition impacts on the patient’s daily living and the expected improvement this intervention will provide.
Individual Funding Request (IFR) Application Forms
should be returned
by Post: / by Confidential Email:
IFR
NHS North and East London Commissioning Support Unit
2nd Floor
Clifton House
75-77 Worship Street
London
EC2A 2DU
Contact the IFR team by telephone on:
020 3688 1290 / / Barking and Dagenham
Havering
Redbridge
/ Waltham Forest
Newham
Tower Hamlets
City and Hackney
/ Barnet
Camden
Enfield
Haringey
Islington

GUIDANCE NOTES FOR CLINICIANS COMPLETING THIS IFR FORM

IFR Policy and further information

The IFR Policy and other policy documents areavailable from the IFR team, please contact the team on the relevant email on page 5.

Before submitting an IFR, please check that this is the correct process. IFRs can be submitted by an NHS consultant, a GP or dental practitioner, or an equivalent autonomous practitioner where he/she will be responsible for administering the treatment. The requesting clinician is responsible for providing all supporting information and evidence.

Information Governance and patient consent

Providing either a signature or tick box validates this request and indicates that you have discussed the request with the patient, and that the patient has given consent to the submission. If this section is left incomplete the form cannot be accepted, and we will inform you of this accordingly.

Details of patient and clinician submitting the request

It is essential that you please provide full contact details including an nhs.net email address, to enable us to easily communicate with you while this case is being processed, and to inform you of the final outcome.

We must be able to identify the patient; provision of the patient’s NHS number is also essential. Please note that patient details will not be available to the Panel to ensure anonymity. Please help the IFR Team by not referring to the patient name or initials within the form – the only section which should contain patient demographic details is page 2, which will be anonymised for Panel.

Diagnosis and the patient’s current condition/ Intervention for which funding is requested

The fullest possible information will help the Panel make a decision. Please ensure all relevant sections are completed depending on the type of intervention.

Statement of clinical exceptionality

Clear evidence of patient exceptionality is essential in order to enable the IFR Panel to reach a funding decision. Please state as clearly as possible, with reference to the existing policy if relevant, why this patient should be treated as an exception. Evidence must be submitted to demonstrate how this patient’s clinical condition is significantly different to other patients with a similar condition, and in addition how this patient is likely to gain a greater health benefit compared to others in the cohort of similar patients.

The IFR Team aims to deal with all applications in a timely manner. A funding outcome can only be reached where sufficient information is available to inform the decision. Urgency will be evaluated on the basis of clinical need.

Please contact the IFR Team on 020 688 1290 for further information or clarification.

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