Get Individual Funding Request Form Confidential Incomplete 2020-2025

Filling out the individual funding request form can be an essential process for obtaining necessary medical treatments. This guide provides step-by-step instructions to help you complete the form accurately and effectively.

Follow the steps to complete your individual funding request form correctly.

1. Click the ‘Get Form’ button to access the individual funding request form and open it in your preferred online editor.
2. Begin with Section 1, entering patient details such as the ID number, NHS number, date of birth (DOB), initials, and postcode. Ensure that all provided information is accurate and complete.
3. Proceed to Section 2 for the referrer’s details. Fill in the contact number, name, and address of the person submitting the request. Indicate whether a GP referral is applicable by selecting 'Yes' or 'No', and provide the GP and consultant signatures along with the dates.
4. In Section 3, clinical details are crucial. Enter the clinical specialty, diagnosis, brief history of the patient, and any requested treatment, particularly if surgical intervention is involved. Be sure to include the current Body Mass Index (BMI) if applicable.
5. Continue in Section 3 by stating the reason for the funding request. Indicate if the patient meets eligibility criteria against agreed protocols. If not, describe the exceptional clinical circumstances justifying the request.
6. If applicable, confirm whether the request has been evaluated by the Drugs & Therapeutics Committee (DTC). Provide details about any decisions made by the DTC.
7. Input information about the proposed treatment provider, estimated cost, duration of the treatment, and the level of urgency for the request.
8. In Section 4, detail any supporting evidence such as relevant NICE guidance or clinical trials that justify the funding request.
9. Finally, review all sections for completeness and accuracy. Once confirmed, you can save your changes, download a copy, print the form, or share it as necessary.

Complete your individual funding request form online today to ensure timely processing of your request.