Excluded: Procedure not routinely funded Application form: - Functional Electrical Stimulation - new requests (Policy 59) 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. Please note that that FES will only be considered for patients with foot drop. 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 before treatment. Email the completed document and papers to the IFR service at: 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 for treatment Please tick and add details where requested What condition does the patient have? Please give full clinical details. What other treatments has the patient received for this condition? Please give full details outlining each treatment and the outcome of the treatment. Has the patient had a trial of FES of at least 3 months? YES NO Please provide details. Is the patient able to manage the use of the device and is compliant with it? YES NO How has the patient benefitted from the trial of FES? Please provide details. the above improvements be attained using alternatives such as ankle foot orthoses? Why can’t
Excluded: Procedure not routinely funded Application form: - Functional Electrical Stimulation - new requests (Policy 59) 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. Please note that that FES will only be considered for patients with foot drop. 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 before treatment. Email the completed document and papers to the IFR service at: 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 for treatment Please tick and add details where requested What condition does the patient have? Please give full clinical details. What other treatments has the patient received for this condition? Please give full details outlining each treatment and the outcome of the treatment. Has the patient had a trial of FES of at least 3 months? Please provide details. YES NO Is the patient able to manage the use of the device and is compliant with it? YES NO How has the patient benefitted from the trial of FES? Please provide details. Why can’t the above improvements be attained using alternatives such as ankle foot orthoses?
FES-New-Request-Form-BD-v1.1.docx