Procedure that requires prior approval Application form: - Male Circumcision (Policy 08) Name of Referring Clinician GP Name and Surgery Patient NHS Number Is the patient/guardian aware of the proposed treatment and have they consented to you Yes No raising this request on their behalf? Has the patient/guardian consented for their personal and clinical information to be provided Yes No to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? Is this a patient/guardian led application? Yes No Most Urgent: Decision needed within a week as the be in danger. patient’s life may Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. Routine: Decision needed in 4 to 6 weeks. This form is to be completed by the GP/Consultant when applying for funding for individual patients for clinical procedures which require Prior Approval or Procedures Not Routinely Funded. Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration. The policy statements are available at: Please note that unless there are exceptional health needs clearly demonstrated in the form which are deemed acceptable by the panel, it is unlikely that funding will be approved. Please complete the following sections in full. Incomplete applications will not be considered and will be returned. Clinical Criteria required for consideration of treatment Please Tick Permanent scarring of the preputial orifice, pathological phimosis (inability YES NO to retract the foreskin due to narrow preputial ring) and paraphimosis (inability to pull forward a retracted foreskin). Please provide clinical details. Balanitis Xerotica Obliterans (chronic inflammation leading to a rigid YES NO fibrous foreskin). Please provide clinical details. Severe Recurrent Balanoposthitis (three or more bacterial infections of the YES NO prepuce)/ Balanitis Please provide clinical details.
Procedure that requires prior approval Application form: - Male Circumcision (Policy 08) Name of Referring Clinician GP Name and Surgery Patient NHS Number Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf? Yes No Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? Yes No Is this a patient/guardian led application? Yes No Most Urgent: Decision needed within a week as the patient’s life may be in danger. Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. Routine: Decision needed in 4 to 6 weeks. This form is to be completed by the GP/Consultant when applying for funding for individual patients for clinical procedures which require Prior Approval or Procedures Not Routinely Funded. Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration. The policy statements are available at: Please note that unless there are exceptional health needs clearly demonstrated in the form which are deemed acceptable by the panel, it is unlikely that funding will be approved. Please complete the following sections in full. Incomplete applications will not be considered and will be returned. Clinical Criteria required for consideration of treatment Please Tick Permanent scarring of the preputial orifice, pathological phimosis (inability to retract the foreskin due to narrow preputial ring) and paraphimosis (inability to pull forward a retracted foreskin). Please provide clinical details. YES NO Balanitis Xerotica Obliterans (chronic inflammation leading to a rigid fibrous foreskin). Please provide clinical details. YES NO Severe Recurrent Balanoposthitis (three or more bacterial infections of the prepuce)/ Balanitis Please provide clinical details. YES NO