Download Orthodontic form - Funding Requests

ENGLAND
INDIVIDUAL REFERRAL – ORTHODONTIC CARE
(Over 18’s and appeals only)
Please complete this form for referral to the appropriate Individual Funding Request team for consideration if as a
clinician you believe that the case of an individual patient is so singular as to justify an exception to the national policy
for NHS orthodontic care. All requests should be provided by the patient’s General Dental Practitioner, in writing and
supported by a clear description of the exceptional circumstances, copies of any relevant correspondence and other
supporting documentation e.g. robust evidence of clinical effectiveness, consultant and other specialist assessments
and may include study models etc.
Please note that you must complete all sections of this form. If all sections are not completed, the form will
be returned to you and will not be referred for action as appropriate.
SECTION ONE – PATIENT DETAILS
SECTION TWO – DETAILS OF REFERRER
Patient Name
Name of Referrer
Date of Birth
Signature
Contact Tel(s):
Date
Address
Practice Stamp
(Address and
Contact Tel):
Post Code
GP Practice
Name and
Address
SECTION THREE – REFERRAL HISTORY
Please provide below details of the patients medical history relevant to this referral:
SECTION FOUR – INDEX OF TREATMENT NEED
Please provide details of the patients IOTN and other relevant measures (if appropriate)
See this link for guidance http://www.learn-ortho.com/IOTN-1.html
SECTION FIVE – PREVIOUS REFERRAL(S)
Has the patient been referred previously via this process? (please tick)
Yes
OFFICE USE ONLY:
REFERENCE NO:
CONTINUATION SHEET – PAGE 2 OF 2
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No
Patient Name:
Date of Birth:
SECTION SIX – REASON FOR REFERRAL
Please provide below any additional information to support the referral in response to the following:
Please describe the long-term impact of this condition on the patient’s oral function and/or oral
health and why this patient/ condition is exceptional. (Please note that inability to pay for
private care is not a criterion for support)
Please describe the long-term benefits for the patient if this treatment is provided and why this
patient will benefit more than might normally be expected for patients with that condition.
SECTION SEVEN – OTHER COMMENTS
Please detail any other comments relevant to this referral below:
(Are there any special circumstances which need to be considered?)
SECTION EIGHT – ADDITIONAL DOCUMENTATION
Please list below any additional documentation included to support this referral: Study models
can be included to evidence exceptional capacity to benefit from treatment (pls ensure they are
securely wrapped to avoid damage). Appropriate radiographs should be included where
relevant to the case.
Please include a copy of the completed NHS orthodontic referral form
PLEASE SEND COMPLETED FORMS TO:
IFR Team, NHS South Commissioning Support Unit, 112 Southampton Road, Eastleigh
SO50 5PB or FAX to: 023 8062 0343.
Any queries please telephone: 023 8062 3254/5/6 or 3269.
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