Part C: INDIVIDUAL FUNDING REQUEST Only Complete if Patient DOES NOT MEET THE CRITERIA IN PART B Exceptionality Please note that not meeting the criteria is not in itself exceptional. The sections below must be completed, clearly outlining a comprehensive and thorough case for the exceptionality of your patient, to enable the IFR Panel to reach a funding decision. Explain why the patient is significantly different to the general population of patients with the condition in question Explain why the patient is likely to benefit more from the intervention than might normally be expected for patients with that condition Brief and relevant health history, including patient’s current health status and any other co-morbidities, health issues and current medication. Clinical History relevant to the case What treatments has the patient tried? Is this patient unable to tolerate the usual care? What services has the patient been referred to? The completed form should be sent in confidence with any other supporting documents to: North Somerset Area Bristol / South Gloucestershire Areas By email to: By email to: If for some reason you are unable to send your If for some reason you are unable to send your application via email, please contact the Referral application via email, please contact the IFR Team Service for guidance. for guidance. In order to comply with information governance standards, emails containing identifiable patient data should only be sent securely, i.e. from an nhs.net account.
Part C: INDIVIDUAL FUNDING REQUEST Only Complete if Patient DOES NOT MEET THE CRITERIA IN PART B Exceptionality Please note that not meeting the criteria is not in itself exceptional. The sections below must be completed, clearly outlining a comprehensive and thorough case for the exceptionality of your patient, to enable the IFR Panel to reach a funding decision. Explain why the patient is significantly different to the general population of patients with the condition in question Explain why the patient is likely to benefit more from the intervention than might normally be expected for patients with that condition Brief and relevant health history, including patient’s current health status and any other co-morbidities, health issues and current medication. Clinical History relevant to the case What treatments has the patient tried? Is this patient unable to tolerate the usual care? What services has the patient been referred to? The completed form should be sent in confidence with any other supporting documents to: North Somerset Area By email to: If for some reason you are unable to send your application via email, please contact the Referral Service for guidance. Bristol / South Gloucestershire Areas By email to: If for some reason you are unable to send your application via email, please contact the IFR Team for guidance. In order to comply with information governance standards, emails containing identifiable patient data should only be sent securely, i.e. from an nhs.net account.
Desensitising_Light_Therapy_PA_Application_v1617.1.02.docx