Download Treatment Request Form

TREATMENT REQUEST FORM
Section A – patient and referring clinician details
Patient details
Surname
Referring clinician details
Applicant Name
Forename(s)
Contact / Email
Address and Post Code
Practice Address and Post Code
Date of Birth
GP Name & Contact Details, if not the
referrer
NHS No.
Gender
Entitled to NHS treatment?
Yes / No
Is the Patient aware that this approval
request has been made to the PCT?
Date Received (PCT Use)
YES / NO
Has the patient received a copy of all the
information forwarded to the PCT?
Patient Initials (PCT Use)
YES/NO
Section B – please complete for ALL requests
Patient Diagnosis / Issue
Details of intervention requested:
Specify:

Provider

Procedure

Course of treatment

Trial

Other
What are the exceptional circumstances?
Definition of exceptionality:

He/she is different to
the general population
of patients who would
normally be refused the
health care intervention
AND

there are good grounds
to believe the patient is
likely to gain
significantly more
benefit from the
intervention than might
be expected for the
average patient with
that particular condition.
What are likely consequences for patient if this application is not
approved?
• Future health
• Potential use of healthcare
services
• Financial cost to patient
What is the evidence-base for this intervention?
Clinical effectiveness, costeffectiveness;
Assessments / publications
by advisory bodies
(please attach)
Has patient been seen by a local consultant, if appropriate?
If not, why are local services
not sufficient?
Please indicate cost of proposed treatment:
Where possible
Section C – Please complete for requests for drug treatments
Further details of intervention (for which approval is requested)
Dose and frequency
Planned duration
Of intervention
Exit strategy / stopping
criteria
(e.g. disease
progression, poor
response, adverse
events)
Route of administration
Anticipated cost (inc
VAT) – seek advice
from pharmacy
Is requested
intervention part of a
clinical trial?
Delete as appropriate: No / Yes
If Yes, give details (e.g. name of trial, is it an MRC/National
trial?)
What would be the standard intervention at this stage (including cost)?
What are the exceptional circumstances that make the standard intervention
inappropriate for this patient?
In case of intervention for
cancer:
What is disease status? (eg. at presentation,1st, 2nd or
3rd relapse)
What is the WHO performance status?
How advanced is the cancer? (stage)
Describe any metastases:
In case of intervention for noncancer:
What is the patient’s clinical severity? (Where possible
use standard scoring systems e.g. WHO, DAS scores,
walk test, cardiac index etc.)
Summary of previous
intervention(s) this patient has
received for the condition.
Dates
Intervention (e.g.
drug / surgery)
* e.g. Course completed / No
or poor response / Disease
progression / Adverse effects
or poorly tolerated
Anticipated start date
Processing requests can take
up to 2 weeks (from the date
received by the PCT). If the
case is more urgent than this,
please state why:
PLEASE CONTINUE ON A SEPARATE SHEET IF NECESSARY
Please send
completed form and
accompanying
documents to:
Mrs Janet Wade
Senior Nurse Case Manager
NHS Rotherham
Oak House
Rotherham
S66 1YY
Reason for
stopping* /
Response
achieved