Team to receive and review confidential clinical information about their health to enable full consideration of this funding request. Yes I confirm all of the above. No In submitting this application you are under obligation to advise the patient or patient representative of the details of the reasons for the decision. Yes I confirm that I will advise the patient or patient representative of No the reasons for the decision. The patient or patient representative will receive a letter outlining that a decision has been made and what that decision is, although will not receive the detail for that decision. Yes No I confirm that it is clinically appropriate for the patient to be informed of the outcome of this IFR. I understand that by indicating that it is NOT clinically appropriate for the IFR Team to contact the patient or patient representative with the outcome, I will be fully responsible to do this. I will inform the patient or patient representative of the outcome Yes and the reasons for the decision. N/A Section 4 TREATMENT – Primary diagnosis most relevant to this IFR request and any relevant co-morbidities: Intervention details including treatment modality (if applicable), how and where the treatment will be given: Is there is an existing clinical policy for this treatment and condition? Please provide explicit reasons why your patient does not meet the access criteria within that policy. Cost What are the costs of the Total cost intervention? Single treatment Where appropriate include here Multiple treatments Cost per Total cost: the total cost of the treatment, any treatment: loading doses required and the number of cycles applied for. Additional comments on the costs of the intervention: What are the total costs of standard therapy (estimate annual costs if applicable)? Are there any offset costs Yes (provide details)? No Clinical Outcomes What are the intended clinical outcomes and how will the
Team to receive and review confidential clinical information about their health to enable full consideration of this funding request. I confirm all of the above. Yes No In submitting this application you are under obligation to advise the patient or patient representative of the details of the reasons for the decision. I confirm that I will advise the patient or patient representative of the reasons for the decision. Yes No The patient or patient representative will receive a letter outlining that a decision has been made and what that decision is, although will not receive the detail for that decision. I confirm that it is clinically appropriate for the patient to be informed of the outcome of this IFR. Yes No I understand that by indicating that it is NOT clinically appropriate for the IFR Team to contact the patient or patient representative with the outcome, I will be fully responsible to do this. I will inform the patient or patient representative of the outcome and the reasons for the decision. Yes N/A Section 4 – TREATMENT Primary diagnosis most relevant to this IFR request and any relevant co-morbidities: Intervention details including treatment modality (if applicable), how and where the treatment will be given: Is there is an existing clinical policy for this treatment and condition? Please provide explicit reasons why your patient does not meet the access criteria within that policy. Cost What are the costs of the intervention? Where appropriate include here the total cost of the treatment, any loading doses required and the number of cycles applied for. Single treatment Total cost Multiple treatments Cost per treatment: Total cost: Additional comments on the costs of the intervention: What are the total costs of standard therapy (estimate annual costs if applicable)? Are there any offset costs (provide details)? Yes No Clinical Outcomes What are the intended clinical outcomes and how will the
ifr-application-form-nov-17.docx