Folder Funding Request Referral Forms

Please select and complete the relevant funding request form, your completed form should be emailed over to the IFR team: This email address is being protected from spambots. You need JavaScript enabled to view it.

If you are seeking funding for a treatment which is covered by a current Service Restriction Policy and you believe that the patient meets all relevant criteria. Please use form A: Prior approval form.

If you are seeking funding for a treatment which is covered by a current Service Restriction Policy but the patient does not meet the current criteria and you are applying for exceptional funding. Please be aware that it is likely that a group of patient will benefit from the treatment or procedure. Please use form B: Exceptional clinical circumstances form.

If you are seeking funding for a treatment/technology for a medical condition where the CCG has no established commissioning policy and it is likely that your patient will be the only patient within the West Essex CCG requiring this treatment or procedure. Form C: Individual Funding Request form.

Drugs requests only: Please use form D.1 Exceptional clinical circumstances 
                                      Please use form D.2 Individual funding request

If you wish to discuss any service restriction policy or funding request please telephone the IFR Coordinators on 01992 566150.

Documents

Toggle Title Date
document A Form Funding request application form (2) ( docx, 68 KB ) (773 downloads) Popular
document B Form SRP Clinically Exceptionality Form Sept 2017 ( doc, 95 KB ) (546 downloads) Popular
document C Form No Policy clinically Exceptionality Form Sept 2017 ( doc, 94 KB ) (526 downloads) Popular
document D.1 Exceptionality Individual Funding Request Form ( docx, 92 KB ) (571 downloads) Popular
document D.2 Individual Funding Request Form ( docx, 88 KB ) (577 downloads) Popular