PDF, 102kb - NHS Choices

FUNDING FOR TREATMENT IN THE EUROPEAN ECONOMIC AREA (EEA)
APPLICATION FORM
Guidance Notes
This form can be completed by a person other than the patient e.g. a family member or a
clinician. However, all the information provided should be about the patient. (Parts 9 and 10 of
this form require the applicant to provide details if they are applying on behalf of the patient).
We can only communicate with the patient / applicant about the application, unless we have the
written consent from the patient regarding anyone else they wish us to communicate with.
Please read the accompanying guidance, on NHS Choices, before completing this form:
http://www.nhs.uk/NHSEngland/Healthcareabroad/plannedtreatment
Notes on the S2 application route:
• Applications must be authorised by the NHS England European Cross Border Health Care
Team before treatment.
• The treatment must be provided in the state healthcare system of the other country.
• Please note that the healthcare providers (from this point referred to as “providers”) may be
either private or state providers. However, some private providers offer treatment for the state
system and some state providers offer treatment privately.
• It is therefore very important that you check whether the provider will accept an S2 form to
fund the treatment(s) you are applying for.
• Applications for Maternity S2 funding must be made directly to the Department for Work and
Pensions (DWP), and not to this team (see NHS Choices for further information).
• S2 applications cannot cover experimental treatments or drug trials.
EU Directive application route:
• Reimbursement can only be made for treatments that would be available to you under the
NHS. If you are unsure whether a treatment would be available to you under the NHS, please
contact your local Clinical Commissioning Group (CCG) or NHS England before you receive
treatment or apply for funding. Find out more on entitlements here:
www.nhs.uk/nhsengland/healthcareabroad/plannedtreatment/pages/article56.aspx
• Depending on the complexities of your individual case, it may be necessary to request further
information for your application to be assessed correctly.
• Most applications can be made either before or after treatment. However, applications for
‘specialised’ treatments require ‘prior authorisation’ and must be approved by NHS England
prior to treatment. A list of such treatments can be found on NHS Choices.
• The treatment received can be in either the state or private healthcare system
Reimbursement: Only treatment costs can be assessed for reimbursement. Travel and
accommodation will not be reimbursed, including for those who may be accompanying you on
your trip abroad. Translation costs are also not covered.
Proof of residence: You must send 2 examples of official evidence showing you are resident at
the stated address, covering the treatment period (see checklist, Part 11, 1). NHS England can
only process applications for patients ordinarily resident in England.
You are responsible for providing accurate and complete information in the application. This will
form the basis of the decision making process. Incomplete applications cannot be processed.
Please ensure that you complete the application check list before submitting the form.
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Part 1: Application Route
Treatment
On what basis is the treatment being provided?
Private system
Before / after
treatment
or
State system
I am applying before receiving treatment in another EEA country
I am applying after receiving treatment in another EEA country
Application
route
S2: I want to apply for funding via the S2 route (before treatment only in
the state system)
(please tick one
box only.
Directive - pre: I want to apply before treatment, for funding for
treatment not classed as ‘specialised’ (state or private)
Complete a
separate
application form
for each
category)
Directive - post: I want to apply after treatment, for funding for
treatment not classed as ‘specialised’ (state or private)
Directive - Specialised: I want to apply before treatment, for funding for
a specialised treatment subject to prior authorisation (state or private)
Medical Delay Are you seeking treatment abroad because of a medical delay in being
treated by the NHS?
Yes
No
If Yes, please provide evidence that this delay was deemed to be “medically
unacceptable” and assessed as such by a UK NHS clinician.
Part 2: Patient Details (Please record clearly, in BLOCK CAPITALS)
Family name
First name(s)
Date of Birth
Sex
Telephone number(s)
Email address
This is normally a 3-3-4
digit format
NHS number
National Insurance No.
Permanent address in England (inc. postcode)
Alternative address for correspondence (if applicable)
GP Name / Registered GP practice (this must be the GP you were registered with at the time
of the treatment you are applying for):
GP address (inc. postcode)
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Are you exempt from any
NHS charges (e.g.
prescription / dental /
ophthalmic charges)?
No
Yes
Please tick which type(s) of exemption:
Prescription charges
Dental treatment
Sight tests
Other:
Glasses / contact lenses
_____________________________
Reason for exemption: _____________________________
Evidence of exemption provided
For further guidance on exemptions (HC12):
http://www.nhs.uk/NHSEngland/Healthcosts/Documents/HC12%20April%202013.pdf
Part 3: Treating Clinician / Provider Details
Please provide details of the main establishment(s) in the EEA, where you were treated /
are going to be treated (in relation to the treatments for which you are applying for
funding). If this involves more than one establishment, please provide details separately sheet.
Treating clinician name
Name of establishment
Address
Country
Telephone number(s)
Email address
Fax number
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Part 4: Treatment Details
(in relation to this application)
a)
What is the DIAGNOSED medical condition for which you have received /
are planning to receive treatment(s) abroad?
b)
Describe the TREATMENT(S) you have received / are planning to receive
abroad.
c)
Is a Clinician’s letter / report attached:
Yes
No
A letter / report must be attached from your Clinician, describing your condition /
diagnosis, and confirming the medical need for the treatment(s). The letter /
report must clearly state why the treatment received will be / was needed.
For S2 applications:
1) The clinician’s letter / report must be from a UK NHS Consultant, on NHS
letterhead, and must support the treatment(s) being carried out in the
proposed country.
2) We also require written confirmation from the provider of: the agreed
treatment(s), treatment dates and estimated costs.
For Directive applications: The letter / report must be from an EEA Clinician
e.g. Consultant / GP (which includes a UK Clinician).
If the letter / report is provided by a Clinician from another EEA country, please
ensure this is in English or that an English translation is provided. You may
provide an accurate translation yourself, but please sign and date.
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d)
What are / were the specific DATE(S) for the treatment(s) abroad?
(complete where applicable)
In-patient stays
(i.e. overnight stays
in hospital)
Day case
appointments (e.g.
day case surgery)
Out-patient
appointments (e.g.
clinics / check-ups /
consultations)
Other
appointments
(e.g. physiotherapy)
Diagnostics tests
(e.g. Blood tests /
scans)
Equipment /
Appliances issued
(e.g. walking aids,
hearing aids)
Continue on a separate
sheet if required
Medication Name
Type (e.g.
tablets, gel,
cream, liquid)
Strength
(e.g. 50mg)
Quantity (e.g.
1 x box 50
tablets, 1 x
100ml bottle)
Drugs / Medication
paid for
Other, please
specify
e)
Are you applying before treatment?
If Yes go to (f), below, if No go to (g)
f)
What are the estimated costs of the treatment?
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Yes
No
Post Treatment Costs
Please note that you will only be reimbursed for items / treatments clearly recorded in the table
below and supported by proof of payment documentation, as detailed below.
Please also number / batch your receipts to match your entries.
All of the entries must also be covered by a clinician’s letter / report (inc. medication).
You must also provide English translations, where these documents are not in English.
g)
Proof of Payment (POP) – documentation
Record the method of payment in the end column, providing the following evidence:
Cash
Credit Card
On-line transfer
Cheque
Receipt
Number
e.g.
1)
Date of
receipt
20/01/14
Invoice – Original
Invoice – Original
Invoice – Original
Invoice – Original
Cash receipt from the provider showing payment – Original.
Credit card statement showing transaction to provider - Copy
Bank statement showing transaction to provider - Copy.
Receipt & bank statement showing cashed cheque - Copy.
Establishment paid
Treatment(s) covered
Hôpital Européen
GeorgesPompidou
Blood test
1)
2)
3)
Please continue on an additional
sheet if you need more space and
tick here
TOTAL CLAIMED
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Amount
paid (state
currency)
10,00
Euros
Method of
Payment
E.g.
Cash
h)
What treatments (if any) are you already receiving / have received, for this
condition, and please indicate if any are / were on the NHS?
i)
Have you applied for funding, via the NHS, for this treatment before?
Applied for funding:
Yes
No
Funding approved:
Yes
No
If Yes, provide further details, including dates / reference numbers (previous EU
reference number or other NHS reference number):
_______________________________________________
Details:
If No, provide the reason why funding was not approved:
j)
Is the application in relation to emergency / urgent (unplanned) treatment
abroad?
Yes
No
If Yes, did you try to use your European Health Insurance Card (EHIC)?
Yes
No
Didn’t have an EHIC card
If you tried to use your EHIC card, was it accepted by the provider?
Yes
No
If no, please record the reason below why the provider would not accept it:
k)
Did you have travel insurance?
Yes
No
If yes, please state why you are applying for NHS funding rather than making an
insurance claim.
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Part 5: Residence
By ticking the following box, I confirm that I am ordinarily resident in England (living
lawfully, on a settled basis), and entitled to receive NHS services:
Are you currently residing at the permanent address you have provided on page 2?
Yes
No
Is this address your permanent residence at the time of treatment?
Yes
No
If No: Where are you currently residing (address / country)? ____________________________
_______________________________________________________________________
How long have you been there? _____________________________________________
How long are you intending to reside there? ___________________________________
What is the reason for you not currently residing at your permanent address (e.g. work, study,
health)? _____________________________________________________________________
Part 6: Supporting information
(please reference Part / Question number and continue on a separate sheet if needed)
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Part 7: Declaration by the Patient
I declare that all the information provided is correct and complete. I understand and accept that if
I knowingly withhold information or provide false or misleading information, I may be liable to
prosecution and/or civil proceedings.
I consent to the disclosure of all information relating to my application to and by NHS England,
the Department of Health, the Department for Work and Pensions (DWP), NHS Protect and
other NHS organisations / external parties, necessary for the processing and verification of this
claim and the investigation, prevention, detection and prosecution of fraud.
I understand that the NHS is not liable for the care received abroad when funded via the S2 or
Directive route.
If applying for reimbursement of costs, I hereby confirm that I have received the treatment(s)
described and understand that the person who received and paid for treatment(s), will normally
receive any reimbursement due.
I hereby give permission for the person identified as the Applicant in Part 9 of this form to make
this application on my behalf (if applicable).
Name of patient
Signature of patient
Date
Part 8: Confirmation of the Applicant
Are you (the patient) also the applicant?
Yes
No – Please complete Parts 9 & 10
Part 9: Declaration by the Applicant
I declare that I am applying with the consent of the patient / I am legally empowered to act on
behalf of the patient (delete as appropriate)
Name of applicant
Signature of applicant
Date
Part 10: Details of the Applicant
Family name
First name(s)
Relationship to patient
Title
Telephone number
Email
Applicant’s address
(for correspondence)
Please note, even if you are acting on behalf of the patient, proof of the patient’s residence, as
per the guidance notes, must still be submitted. Parents applying on behalf of their children are
required to submit evidence of their own residence for the permanent address given (and the
signature of the child, as the patient, is not required).
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Part 11: Application Check List
(you must complete this section prior to submitting your form)
1.
2 x Proof of residence for permanent address (covering treatment period).
One must be a bank statement (showing day to day transactions), along with
one other official document linked to your residency e.g. utility bill / council tax bill
or tenancy / rental agreement. Please contact us for further advice, if required.
2.
Clinicians letter supporting medical need (English translation required).
3.
S2 only – written confirmation from the provider of the treatment(s) of the:
agreed treatment(s), dates and the estimated costs.
4.
Invoices and receipts / proof of payment, for items included in Part 4
(Section g) (English translation(s) required).
5.
Evidence of exemption from patient charges (if applicable).
6.
All sections of the application form completed.
7.
Signatures (patient / applicant).
8.
Security Question and Answer: Q: _________________________________
(please provide for phone call
ID verification
A:__________________________________
Supporting Documentation
This team only requires the original receipts / Proof of Payment documents, as
outlined in section 4(g). All other supporting documentation can be copies.
We cannot accept responsibility for documents lost in transit.
Translations should be signed / dated / stamped.
Please note that this application will not be processed until all of the necessary
supporting information has been received. Incomplete applications will
therefore be put on hold, and not processed, until complete.
Please send your completed form and accompanying documents to the following address:
European Cross Border Healthcare Team
NHS England
Fosse House, 6 Smith Way
Grove Park, Enderby
Leicester, LE19 1SX
Or email: [email protected]
Please note: It can take up to 20 working days for a fully completed application to be processed
and a decision to be made. You will be informed of the outcome of your application once a
decision has been reached. If approved, the reimbursement can take up to a further 30 working
days to be processed.
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