BHR CCGs GP Application form for IFR Applications and POLCE applications where patient does not meet Prior Approval criteria

IMPORTANT - before completing this form, please refer to the Procedures of Limited Clinical Effectiveness policy (POLCE) and/ or the IFR policy

This form should be used for IFR applications, including applications for POLCE listed treatments where the patient does not meet the Prior Approval criteria.

  • Please ensure all relevant boxes are complete. Incomplete forms will be returned
  • Please use the designated NHS.net address for emailing this confidential information.

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)
Procedure requested:
Indication:

Contact Information:

Date of application
  1. Applicant details
/ Name
Designation
Tel
Email – please provide secure nhs.net address
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:
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?)
Cost 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:
  1. Clinically different to the general population of other patients with the same condition?
  1. Likely to gain significantly more 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.
This form should be sent from an nhs.net secure email account to:
Please call 0203 688 1290if you need support to complete this form.

Page 1 of 4