Please continue on separate sheet where needed. This should include the patient’s name and NHS number, and also be signed and dated by the referring clinician. I, an appropriate clinician, confirm that I have explained to the individual/their representative (tick as appropriate): the reasons why a Fast Track application for NHS Continuing Healthcare has been made to the CCG. that the purpose of this is to enable the individual’s needs to be urgently met as they have a rapidly deteriorating condition which may be entering a terminal phase. that their needs may be subject to a review, and accordingly that the funding stream may change subject to the outcome of the review Please ensure this form is sent directly to the CCG without delay Name and signature of referring clinician Date Name and signature confirming approval by CCG Date
Please continue on separate sheet where needed. This should include the patient’s name and NHS number, and also be signed and dated by the referring clinician. I, an appropriate clinician, confirm that I have explained to the individual/their representative (tick as appropriate): the reasons why a Fast Track application for NHS Continuing Healthcare has been made to the CCG. that the purpose of this is to enable the individual’s needs to be urgently met as they have a rapidly deteriorating condition which may be entering a terminal phase. that their needs may be subject to a review, and accordingly that the funding stream may change subject to the outcome of the review Please ensure this form is sent directly to the CCG without delay Name and signature of referring clinician Date Name and signature confirming approval by CCG Date