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Individual Funding Request (IFR) Application Form Central Midlands Commissioning Support Unit NHS Birmingham Cross City Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Solihull Clinical Commissioning Group NHS Dudley Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Walsall Clinical Commissioning Group NHS Wolverhampton Clinical Commissioning Group APPLICATION FORM FOR INDIVIDUAL FUNDING REQUESTS All sections of the form must be completed otherwise the case will not be considered Important information Before you begin to complete this form and make an application you MUST first consider the following question: Are there similar patients with similar clinical circumstances who could also benefit from the treatment you are requesting across the population of the CCGs? If the answer is YES then making an individual funding request is an inappropriate way to deal with funding for this patient. This is because the case represents a service development for a predictable population. You should discuss with your contract team how you submit a business case for consideration through the usual business planning process. Mandatory field if proceeding with the IFR Are there likely to be similar patients who will receive the same expected benefits from this intervention or clinical trial? If YES, please indicate likely number of patients there are likely to be in a million population. If the answer is NO then please proceed by completing the application, providing the information and relevant evidence for the appropriate category of IFR into which this patient’s case falls. 1 Copyright © 2014 Central Midlands CSU, All rights reserved. (CM CSU use only) Case code: Date Received: Date assessed by IFR Team: IFR Screening Panel Date: IFR Panel Date: Decision: Decision: Decision: Mandatory field 1. Patient Details Forename: Surname: Date Of Birth: Patient’s Address & Postcode: NHS Number: Hospital Number: Sex: M/F: Ethnic Origin: (Please note that all necessary personal information will be removed from this form prior to being reviewed. This information is collected for monitoring purposes only) Mandatory field 2. Patient consent Does the patient provide consent for all information regarding their case to be shared with the Individual Funding Request Panels? If the patient does not have the mental capacity to give informed consent, then please confirm that you have complied with the Mental Capacity Act 2005 and the accompanying Code of Practice. Mandatory field 3. Registered GP Details Registered Practice: Registered GP Practice Address: Registered GP: Telephone no: Email Address: 2 Copyright © 2014 Central Midlands CSU, All rights reserved. YES / NO YES / NO Mandatory field 4. Requesting Clinician Details Name of Provider: Name & Designation of Requesting Clinician: Address: Telephone no: Email Address: Fax Number: Mandatory field 5. Clinical Urgency Is the patient’s application urgent? Processing requests takes on average one month. If the case is more urgent than this, please state why and how urgent the case is Mandatory field for all but requests to enter a patient in a clinical trial 6. Treatment Requested Details of intervention / treatment for which funding is requested: Name of treatment/intervention: If a drug, dose and frequency: Cost of Treatment: Planned duration of intervention (including number of treatments): Cost of the treatment: Detail of associated costs: (including VAT & Associated Inpatient / Outpatient Activity): Anticipated total cost: 3 Copyright © 2014 Central Midlands CSU, All rights reserved. Mandatory field for all but requests to enter a patient in a clinical trial 7. Alternative Treatments What standard treatment does this request replace? Why is the standard treatment not appropriate? What would be the cost of the standard treatment? If this treatment request is not approved, what treatment will be given to the patient? Mandatory field for all but requests to enter a patient in a clinical trial 8. Drug status If a drug treatment is requested, is the drug licensed for the requested indication in the United Kingdom? If not licensed is the request: a) Supported by the trust’s drug and therapeutics committee or equivalent? b) Licensed in any other country? 4 Copyright © 2014 Central Midlands CSU, All rights reserved. Mandatory field for all but requests to enter a patient in a clinical trial 9. Treatment History Details of Diagnosis & Prognosis (for which the treatment is requested): Relevant medical history: (incl. dosage & frequency of all medications and comorbidities) Previous treatments / interventions this patient has received for this condition: Date/s Intervention (e.g. drug. surgery) Reason for stopping / Response achieved Mandatory field for all but requests to enter a patient in a clinical trial 10. Request to treat this patient as an exception Where known, please state which commissioning policy or policies this IFR relates to: Please set out the case for this patient being considered an exception with reference to: The way in which the patient is clinical different to others. The expected benefit expected in this patient. On what evidence you base the assertion that this patient will benefit more than other patients OR Where a request is being made to use a treatment experimentally in an individual case please set out the evidence on which benefit has been inferred. Any other material factors which have bearing on the case. The case can be submitted either on this form or in a letter to be attached to this form. Please attach any evidence in support of the benefit of treatment in this patient you consider is exceptional 5 Copyright © 2014 Central Midlands CSU, All rights reserved. Mandatory for requests to enter a patient into a clinical trial 11. Requests for treatment costs or pick-up costs to enter a single patient into a clinical trial The trial protocol (not the summary) must be submitted with the IFR request. Confirm that the patient meets the clinical entry criteria? Full name of the clinical trial: The trial registration number (state which register): Funding being sought: (please provide a breakdown of all costs) Mandatory – ALL 12. Declaration To the best of my knowledge I have given the most accurate and up to date information regarding this patient’s clinical condition. Name Position/Title Signature Provider Trust support for the application Name Position/Title Signature Date Completed 6 Copyright © 2014 Central Midlands CSU, All rights reserved. On Completion Email through the appropriate Clinical Commissioning Group via the nhs.net account to dedicated email: Birmingham Cross City CCG [email protected] Harinder Kaur 0121 612 1653/612 1659 Birmingham South Central CCG [email protected] Terri-Ann Millington 0121 612 1645/612 1660 Solihull CCG [email protected] Terri-Ann Millington 0121 612 1645/612 1660 Wolverhampton CCG Walsall CCG Sandwell CC Dudley CCG [email protected] Sylvia Woodhall [email protected] Sylvia Woodhall [email protected] Sylvia Woodhall [email protected] Denise Bell 0121 612 1408/612 3512 0121 612 1408/612 3512 0121 612 1408/612 3512 0121 612 1636/612 1661 For generic queries email: [email protected] or Fax to safe haven: 0121 285 5990 or Post (Marked Confidential) to: IFR Team Central Midlands CSU Kingston House 438-450 High Street West Bromwich West Midlands B70 9LD 7 Copyright © 2014 Central Midlands CSU, All rights reserved.