Download otn ipfr orthodontist report

Making Decisions on Assessment Appeals and
Individual Patient Funding Requests (IPFR)
Orthodontist Report
COMPLETING THIS FORM:
1. Please complete this form if, subsequent to an orthodontic examination, a patient or
patient’s parent or guardian appeals against an assessment of treatment need that
is outside of the acceptance criteria for NHS orthodontic care
The form should be completed electronically by the Orthodontic provider. Hand
written forms will not be accepted as errors can be made in interpreting
handwriting).
2. Supporting Evidence: Please also enclose any supporting clinical information you
feel is appropriate.
3. How to Submit the Form and Supporting Information:
 Post - Miss Anne Simpson, Individual Patient Care Services Manager,
Abertawe Bro Morgannwg University Health Board, 1 Talbot Gateway,
Baglan Energy Park, Port Talbot, SA12 7BR
 Fax - 01639 687675
 Email - A word version to [email protected] as long as
signatures are present and it is followed up in hard copy.
CLINICIAN DETAILS
ORTHODONTIST NAME:
PRACTICE ADDRESS/STAMP
SIGNATURE & DATE:
PATIENT DETAILS
PATIENT NAME:
PATIENT ADDRESS (Including postcode):
DATE OF BIRTH:
PATIENT NHS NUMBER:
CONTACT NUMBER
CLINICAL DETAILS
Date of referral:
Date of assessment(s):
Reason for referral:
Patient presenting complaint:
Relevant medical history;
Relevant dental history:
IOTN:
Dental Health Component:
Aesthetic Component:
Please indicate if this request is clinically exceptional?
What is the likely outcome if this treatment is not funded?
Enclosures:
Other:
OPT
Ceph
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