Section G: Statement of Exceptionality or Rarity On which basis are you making Exceptional clinical circumstances (please continue to question 24) this request? * Rarity of condition or presentation (please continue to question 25) If exceptionality, please describe (a) Please describe in why this patient’s clinical detail how the clinical presentation of this circumstances are exceptional * Give specific information in each section patient differs from other opposite to indicate how this patient is patients with this significantly different from the cohort of condition other patients with the same clinical (b) Please describe why condition and how this patient might be expected to gain greater health benefit from this intervention compared to other patients with this condition If rarity, please describe why this (a) Please state the UK UK prevalence: Ref: prevalence and quote the patient’s condition or clinical presentation is so rare or unusual source/reference that there is no relevant (b) Please describe how the commissioning arrangement in clinical presentation of this * patient makes them rare * (c) Please state, how many patients with the same condition or presentation as this patient does your trust / practice expect to see in the next 12 months? * Section H: Costs and Review for Drug or Non Drug Interventions (to be completed by approved NHS provider Chief Pharmacist or Service Manager) * 26. Total acquisition cost (inc VAT) for duration of treatment being applied for and associated costs such as administering a drug, phlebotomy, activity etc * 27. State the value of any offset costs * 28. Please benchmark these costs against London procurement contract prices * 29. Application reviewed by chief pharmacist / service manager or Name: nominated authorised deputy * Signature and confirmation *: SECTION I: APPLICANT’S DECLARATION * 30. Declaration * Yes No I declare that this application is complete and accurate and that all necessary supporting information and evidence has been provided on this form (and attachments) Patient consent * Yes No I confirm that the patient has given their explicit consent for their patient identifiable data to be shared with the following organisations in order to
Section G: Statement of Exceptionality or Rarity On which basis are you making this request? * Exceptional clinical circumstances (please continue to question 24) Rarity of condition or presentation (please continue to question 25) If exceptionality, please describe why this patient’s clinical circumstances are exceptional * Give specific information in each section opposite to indicate how this patient is significantly different from the cohort of other patients with the same clinical condition (a) Please describe in detail how the clinical presentation of this patient differs from other patients with this condition (b) Please describe why and how this patient might be expected to gain greater health benefit from this intervention compared to other patients with this condition If rarity, please describe why this patient’s condition or clinical presentation is so rare or unusual that there is no relevant commissioning arrangement in * (a) Please state the UK prevalence and quote the source/reference UK prevalence: Ref: (b) Please describe how the clinical presentation of this patient makes them rare * (c) Please state, how many patients with the same condition or presentation as this patient does your trust / practice expect to see in the next 12 months? * Section H: Costs and Review for Drug or Non Drug Interventions (to be completed by approved NHS provider Chief Pharmacist or Service Manager) * 26. Total acquisition cost (inc VAT) for duration of treatment being applied for and associated costs such as administering a drug, phlebotomy, activity etc * 27. State the value of any offset costs * 28. Please benchmark these costs against London procurement contract prices * 29. Application reviewed by chief pharmacist / service manager or nominated authorised deputy * Name: Signature and confirmation *: SECTION I: APPLICANT’S DECLARATION * 30. Declaration * I declare that this application is complete and accurate and that all necessary supporting information and evidence has been provided on this form (and attachments) Yes No Patient consent * I confirm that the patient has given their explicit consent for their patient identifiable data to be shared with the following organisations in order to Yes No
IFR-Application-form-north-London-May-2018.docx