Extra Contractual Referrals – Funding Application Form

What is an ECR?

ECR requests are for individual patients requiring treatment or care not provided locally by NHS Borders. All elective treatments to other Boards and English Trusts must be approved through the ECR process before referral, with the exception of some specialised services from Lothian, Newcastle and Carlisle. If you are in any doubt about our contracting arrangements, please contact us on 01896 824535.

You can fax, email or post the completed form:

Fax: Safehaven fax number 01896 823396

Email: Emailing from another borders.scot.nhs.uk account to or is also a safe method of transmission

Post: Marked ‘Private & Confidential’ for the attention of the Commissioning Manager,

Commissioning Team, Room 20, West Grove, Melrose TD6 9SJ

Queries: Telephone 01896 824535

CHI Number: Patient Initials

Name of Referrer: Designation:

Service/GP Practice Tel Contact:

Questions / Comments/Brief Explanation
1. What is the treatment, procedure or appointment patient is being referred for?
2. Is this a one-off treatment, or will ongoing appointments/care or treatment be needed? If ongoing care, please give an indication of the expected duration of care (weeks/months) / Please circle:
One-off Ongoing
Duration:
3. What are your reasons for referring this patient? Please include a short medical background, or provide a supporting letter with full details.
4. What is the clinical evidence to support the use of this treatment? (Please include reference source of evidence based research – if available, e.g SIGN/NICE)
5. Please indicate any treatments the patient has already had/other options for treatment which may have been considered. If discounted, please explain why.

For ECR Administration use only – see overleaf


For ECR Administration use only

Comments/Brief Explanation (must complete)
Approximate Cost of Treatment
Date of NHS Borders ECR panel
Decision on Funding Request / Approved / Denied
Level of Funding Approved
File Number
Pre-Contract Checklist if Independent Sector / Status:
Approved In Progress Not Approved
For children only and adults at risk – have NHS Borders patients been treated by this provider before? Has there been a local assessment of their child & adults at risk protection arrangements? Contact point in provider for child & adult protection arrangements?