TREATMENTREQUEST FORM

Section A – patient and referring clinician details

Patient details / Referring clinician details
Surname / Applicant Name
Forename(s) / Contact / Email
Address and Post Code / Practice Address and Post Code
Date of Birth / GP Name & Contact Details, if not the referrer
NHS No.
Gender
Entitled to NHS treatment?
Yes / No / Is the Patient aware that this approval request has been made to the PCT?
YES / NO
Date Received (PCT Use) / Has the patient received a copy of all the information forwarded to the PCT?
YES/NO
Patient Initials (PCT Use)

Section B – please complete for ALL requests

Patient Diagnosis / Issue
Details of intervention requested: / Specify:
  • Provider
  • Procedure
  • Course of treatment
  • Trial
  • Other

What are the exceptional circumstances? / Definition of exceptionality:
  • He/she is different to the general population of patients who would normally be refused the health care intervention AND
  • there are good grounds to believe the patient is likely to gain significantly more benefit from the intervention than might be expected for the average patient with that particular condition.

What are likely consequences for patient if this application is not approved? / • Future health
• Potential use of healthcare services
• Financial cost to patient
What is the evidence-base for this intervention? / Clinical effectiveness, cost-effectiveness;
Assessments / publications by advisory bodies
(please attach)
Has patient been seen by a local consultant, if appropriate? / If not, why are local services not sufficient?
Please indicate cost of proposed treatment: / Where possible

Section C – Please complete for requests for drug treatments

Further details of intervention (for which approval is requested)
Dose and frequency
Planned duration
Of intervention
Exit strategy / stopping criteria
(e.g. disease progression, poor response, adverse events)
Route of administration
Anticipated cost (inc VAT) – seek advice from pharmacy
Is requested intervention part of a clinical trial? / Delete as appropriate: No / Yes
If Yes, give details (e.g. name of trial, is it an MRC/National trial?)
What would be the standard intervention at this stage (including cost)?
What are the exceptional circumstances that make the standard intervention inappropriate for this patient?
In case of intervention for cancer: / What is disease status? (eg. at presentation,1st, 2nd or 3rd relapse)
What is the WHO performance status?
How advanced is the cancer? (stage)
Describe any metastases:
In case of intervention for non-cancer: / What is the patient’s clinical severity? (Where possible use standard scoring systems e.g. WHO, DAS scores, walk test, cardiac index etc.)
Summary of previous intervention(s) this patient has received for the condition.
* e.g. Course completed / No or poor response / Disease progression / Adverse effects or poorly tolerated / Dates / Intervention (e.g. drug / surgery) / Reason for stopping* / Response achieved
Anticipated start date
Processing requests can take up to 2 weeks (from the date received by the PCT). If the case is more urgent than this, please state why:

PLEASE CONTINUE ON A SEPARATE SHEET IF NECESSARY

Please send completed form and accompanying documents to: / Mrs Janet Wade
Senior Nurse Case Manager
NHS Rotherham
Oak House
Rotherham
S66 1YY