INDIVIDUAL FUNDING REQUEST APPLICATION FORM On completion, please e-mail to IMPORTANT GUIDANCE This form should be read in conjunction with Bedfordshire Clinical Commissioning Group’s Individual Funding Request Policy. Please note that individual case funding should not be requested where the intention is to introduce a new treatment for a definable group of patients (however small). Such requests should be forwarded for consideration by the Bedfordshire Clinical Commissioning Group’s Prioritisation Panel using the appropriate proforma for the introduction of new treatments. The purpose of the Individual Funding Request process is to provide a mechanism for considering the needs of individual patients whose personal circumstances might make them exceptional or individual patients within the terms of the Individual Funding Request Policy. This proforma is designed to facilitate the full and fair consideration of each Individual Funding Request. It should be completed in full in respect of each patient for whom such a request is made. Please also submit any additional information that you wish to be taken into consideration. Please note that the Individual Funding Request process cannot be used to make policy decisions on behalf of the Bedfordshire Clinical Commissioning Group. The Individual Funding Request process cannot make a decision to fund a patient where by so doing a precedent would be set that establishes new policy (because the patient is not, in fact, exceptional but representative of a definable group of patients). If you are uncertain as to whether the Individual Funding process or a policy decision through the Prioritisation Panel is more appropriate, please discuss with the Bedfordshire Clinical Commissioning Group’s Strategy and System Redesign Directorate. Please note that the panel requires all information submitted to be anonymised, the maximum identifiers should be: NHS Number; Gender; Age; GP; to protect patient confidentiality and ensure panel objectivity. Any request submitted without a fully completed application form, the relevant supporting information and clinical evidence, will be returned. For treatments subject to NICE TAGs (and are PBR excluded) or those subject to local policies, please only complete Sections 1 & 2. Fully completed application forms should be saved locally and sent from a secure NHS.net account to for
INDIVIDUAL FUNDING REQUEST APPLICATION FORM On completion, please e-mail to IMPORTANT GUIDANCE This form should be read in conjunction with Bedfordshire Clinical Commissioning Group’s Individual Funding Request Policy. Please note that individual case funding should not be requested where the intention is to introduce a new treatment for a definable group of patients (however small). Such requests should be forwarded for consideration by the Bedfordshire Clinical Commissioning Group’s Prioritisation Panel using the appropriate proforma for the introduction of new treatments. The purpose of the Individual Funding Request process is to provide a mechanism for considering the needs of individual patients whose personal circumstances might make them exceptional or individual patients within the terms of the Individual Funding Request Policy. This proforma is designed to facilitate the full and fair consideration of each Individual Funding Request. It should be completed in full in respect of each patient for whom such a request is made. Please also submit any additional information that you wish to be taken into consideration. Please note that the Individual Funding Request process cannot be used to make policy decisions on behalf of the Bedfordshire Clinical Commissioning Group. The Individual Funding Request process cannot make a decision to fund a patient where by so doing a precedent would be set that establishes new policy (because the patient is not, in fact, exceptional but representative of a definable group of patients). If you are uncertain as to whether the Individual Funding process or a policy decision through the Prioritisation Panel is more appropriate, please discuss with the Bedfordshire Clinical Commissioning Group’s Strategy and System Redesign Directorate. Please note that the panel requires all information submitted to be anonymised, the maximum identifiers should be: NHS Number; Gender; Age; GP; to protect patient confidentiality and ensure panel objectivity. Any request submitted without a fully completed application form, the relevant supporting information and clinical evidence, will be returned. For treatments subject to NICE TAGs (and are PBR excluded) or those subject to local policies, please only complete Sections 1 & 2. Fully completed application forms should be saved locally and sent from a secure NHS.net account to for
bccg_individualfundingrequestformdrugsonlyjuly2016.docx