Application Form for Nhs Funded Care

APPLICATION FORM FOR NHS FUNDED CARE

STRICTLY CONFIDENTIAL

Please return the completed application form to:

Continuing Healthcare applications to:

Continuing Care

Sovereign House

Unit 5 Kettlestring Lane

Clifton Moor

York YO30 4GQ Tel 0300 303 8294

Fast track applications:

Date received (for NHS Continuing Care Admin only): ……………………………………

Request for: / Funded Nursing Care Assessment / Respite
Full/Joint Health Funding / New referral
Fast track application (form attached) / Change in condition
PERSONAL DETAILS
Surname: ……………………………………… / DoB:: ……………………………..
First Name: ……………………………………. / NHS Number: ……………………
Swift No: …………………………..
Title: ……………………………………… / Gender: …………………………………
Address: ………………………………………
………………………………………………….
…………………………………………………. / Discharge address (If different from home)
…………………………………………………..
………………………………………………….
Postcode: …………………………………… / Postcode: …………………………………….
Tel: ………………………………………….. / Tel: …………………………………………….
Discharge date (If known): …………………… / FNC Respite dates (if known): ……………………...
General Practitioner: / Next of Kin/Carer details:
Name: …………………………………………. / Name: …………………………………………
Practice: ………………………………………. / Relationship: ………………………………….
Address: ………………………………………. / Address: ……………………………………….
…………………………………………………… / ……………………………………………………
Postcode: ……………………………………… / Postcode: ………………………………………
Tel: …………………………………………… / Tel: ……………………………………………..

CLIENT’S NAME: ………………………………………………… DoB: ……………………………

Patient’ Current Location:
Home address (please tick box): / □ / Hospital: ………………………………………
Ward: ………………………………………. / Tel: …………………………………………….
Details of other professionals involved:
……………………………………………………… Tel: ………………………………………….
…………………………………………………….. Tel: …………………………………………
……………………………………………………. Tel: …………………………………………
……………………………………………………. Tel: …………………………………………
Care Manager: ………………………………… / Tel: …………………………………….
Office base: ……………………………………………………………………………………
Responsible Local Authority: North Yorkshire/ City of York/ Other …………………………………………
(Please delete as applicable)
Funding Source – FNC only (Please tick box):
Social Services / □ / Self Funding: / □
Diagnosis and Case Summary (Please attach additional sheet if required):
Current Care Arrangements: /

Current Funding Arrangements

Social Services
Cont. Health Care
RNCC
Other PCT
Education/LSC
Supporting People
ILF
Client Contribution
Other

TOTAL

CLIENT’S NAME: ………………………………………………… DoB: ……………………………

Proposed Care Arrangements: / Proposed Funding Arrangements
Social Services
Cont. Health Care
RNCC
Other PCT
Education/LSC
Supporting People
ILF
Client Contribution
Other

TOTAL

Care Provider and Address: / ………………………………………………
………………………………………………
Tel: …………………………………………

For Fast Track Scheme only -

Start Date

/ ………………………………………………………….

Prognosis (If Applicable) and by whom

/ ……………………………………………………………
……………………………………………………………
…………………………………………………………….
Referred by: / ……………………………………………………
Please print name: / ……………………………………………………
Location: / …………………………………………………….
Tel: / ……………………………………………………
Date: / ……………………………………………………

NOTE: PLEASE OBTAIN CONSENT FROM CLIENT/NEXT OF KIN BEFORE RETURNING THIS

FORM. FAILURE TO DO SO WILL DELAY THE PROCESS (See page 4)

To process this application the following documents, signed and dated must accompany this form:
(Not Fast Track Scheme)
Multi disciplinary discharge meeting notes
Nursing assessment, including risk assessment scores
Social services care plan (Fully funded application only)
Other supporting evidence, e.g. OT, Physio, Specialist Nurse

Preferred Language/Ethnicity: ………………………………………………………………………..

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