United Kingdom Funding for Treatment in the European Economic Area (Eea) Application Form Download Printable PDF

FUNDING FOR TREATMENT IN THE EUROPEAN ECONOMIC AREA (EEA)

APPLICATION FORM

Guidance Notes

This form can be completed by a person other than the patient e.g. a family member or a

clinician. However, all the information provided should be about the patient. (Parts 9 and 10 of

this form require the applicant to provide details if they are applying on behalf of the patient).

We can only communicate with the patient / applicant about the application, unless we have the

written consent from the patient regarding anyone else they wish us to communicate with.

Please read the accompanying guidance, on NHS Choices, before completing this form:

http://www.nhs.uk/NHSEngland/Healthcareabroad/plannedtreatment

Notes on the S2 application route:

• Applications must be authorised by the NHS England European Cross Border Health Care

Team before treatment.

• The treatment must be provided in the state healthcare system of the other country.

• Please note that the healthcare providers (from this point referred to as “providers”) may be

either private or state providers. However, some private providers offer treatment for the state

system and some state providers offer treatment privately.

• It is therefore very important that you check whether the provider will accept an S2 form to

fund the treatment(s) you are applying for.

• Applications for Maternity S2 funding must be made directly to the Department for Work and

Pensions (DWP), and not to this team (see NHS Choices for further information).

• S2 applications cannot cover experimental treatments or drug trials.

EU Directive application route:

• Reimbursement can only be made for treatments that would be available to you under the

NHS. If you are unsure whether a treatment would be available to you under the NHS, please

contact your local Clinical Commissioning Group (CCG) or NHS England before you receive

treatment or apply for funding. Find out more on entitlements here:

www.nhs.uk/nhsengland/healthcareabroad/plannedtreatment/pages/article56.aspx

• Depending on the complexities of your individual case, it may be necessary to request further

information for your application to be assessed correctly.

• Most applications can be made either before or after treatment. However, applications for

‘specialised’ treatments require ‘prior authorisation’ and must be approved by NHS England

prior to treatment. A list of such treatments can be found on NHS Choices.

• The treatment received can be in either the state or private healthcare system

Reimbursement: Only treatment costs can be assessed for reimbursement. Travel and

accommodation will not be reimbursed, including for those who may be accompanying you on

your trip abroad. Translation costs are also not covered.

Proof of residence: You must send 2 examples of official evidence showing you are resident at

the stated address, covering the treatment period (see checklist, Part 11, 1). NHS England can

only process applications for patients ordinarily resident in England.

You are responsible for providing accurate and complete information in the application. This will

form the basis of the decision making process. Incomplete applications cannot be processed.

Please ensure that you complete the application check list before submitting the form.

10. EEA application form (04 /15)

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FUNDING FOR TREATMENT IN THE EUROPEAN ECONOMIC AREA (EEA)

APPLICATION FORM

Guidance Notes

This form can be completed by a person other than the patient e.g. a family member or a

clinician. However, all the information provided should be about the patient. (Parts 9 and 10 of

this form require the applicant to provide details if they are applying on behalf of the patient).

We can only communicate with the patient / applicant about the application, unless we have the

written consent from the patient regarding anyone else they wish us to communicate with.

Please read the accompanying guidance, on NHS Choices, before completing this form:

http://www.nhs.uk/NHSEngland/Healthcareabroad/plannedtreatment

Notes on the S2 application route:

• Applications must be authorised by the NHS England European Cross Border Health Care

Team before treatment.

• The treatment must be provided in the state healthcare system of the other country.

• Please note that the healthcare providers (from this point referred to as “providers”) may be

either private or state providers. However, some private providers offer treatment for the state

system and some state providers offer treatment privately.

• It is therefore very important that you check whether the provider will accept an S2 form to

fund the treatment(s) you are applying for.

• Applications for Maternity S2 funding must be made directly to the Department for Work and

Pensions (DWP), and not to this team (see NHS Choices for further information).

• S2 applications cannot cover experimental treatments or drug trials.

EU Directive application route:

• Reimbursement can only be made for treatments that would be available to you under the

NHS. If you are unsure whether a treatment would be available to you under the NHS, please

contact your local Clinical Commissioning Group (CCG) or NHS England before you receive

treatment or apply for funding. Find out more on entitlements here:

www.nhs.uk/nhsengland/healthcareabroad/plannedtreatment/pages/article56.aspx

• Depending on the complexities of your individual case, it may be necessary to request further

information for your application to be assessed correctly.

• Most applications can be made either before or after treatment. However, applications for

‘specialised’ treatments require ‘prior authorisation’ and must be approved by NHS England

prior to treatment. A list of such treatments can be found on NHS Choices.

• The treatment received can be in either the state or private healthcare system

Reimbursement: Only treatment costs can be assessed for reimbursement. Travel and

accommodation will not be reimbursed, including for those who may be accompanying you on

your trip abroad. Translation costs are also not covered.

Proof of residence: You must send 2 examples of official evidence showing you are resident at

the stated address, covering the treatment period (see checklist, Part 11, 1). NHS England can

only process applications for patients ordinarily resident in England.

You are responsible for providing accurate and complete information in the application. This will

form the basis of the decision making process. Incomplete applications cannot be processed.

Please ensure that you complete the application check list before submitting the form.

10. EEA application form (04 /15)

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Part 1: Application Route

Treatment

On what basis is the treatment being provided?

Private system

State system

Before / after

I am applying before receiving treatment in another EEA country

treatment

I am applying after receiving treatment in another EEA country

Application

S2: I want to apply for funding via the S2 route (before treatment only in

route

the state system)

(please tick one

Directive - pre: I want to apply before treatment, for funding for

box only.

treatment not classed as ‘specialised’ (state or private)

Complete a

Directive - post: I want to apply after treatment, for funding for

separate

treatment not classed as ‘specialised’ (state or private)

application form

Directive - Specialised: I want to apply before treatment, for funding for

for each

category)

a specialised treatment subject to prior authorisation (state or private)

Medical Delay Are you seeking treatment abroad because of a medical delay in being

treated by the NHS?

Yes

If Yes, please provide evidence that this delay was deemed to be “medically

unacceptable” and assessed as such by a UK NHS clinician.

Part 2: Patient Details (

Please record clearly, in BLOCK CAPITALS)

Family name

First name(s)

Date of Birth

Sex

Telephone number(s)

Email address

This is normally a

3-3-4

NHS number

digit format

National Insurance No.

Permanent address in England (inc. postcode)

Alternative address for correspondence (if applicable)

GP Name / Registered GP practice (this must be the GP you were registered with at the time

of the treatment you are applying for):

GP address (inc. postcode)

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Are you exempt from any

NHS charges (e.g.

prescription / dental /

Yes

Please tick which type(s) of exemption:

ophthalmic charges)?

Prescription charges

Dental treatment

Sight tests

Glasses / contact lenses

Other:

_____________________________

Reason for exemption: _____________________________

Evidence of exemption provided

For further guidance on exemptions (HC12):

http://www.nhs.uk/NHSEngland/Healthcosts/Documents/HC12%20April%202013.pdf

Part 3: Treating Clinician / Provider Details

Please provide details of the main establishment(s) in the EEA, where you were treated /

are going to be treated (in relation to the treatments for which you are applying for

funding). If this involves more than one establishment, please provide details separately sheet.

Treating clinician name

Name of establishment

Address

Country

Telephone number(s)

Email address

Fax number

10. EEA application form (04 /15)

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Part 4: Treatment Details

(in relation to this application)

What is the DIAGNOSED medical condition for which you have received /

are planning to receive treatment(s) abroad?

Describe the TREATMENT(S) you have received / are planning to receive

abroad.

Is a Clinician’s letter / report attached:

Yes

A letter / report must be attached from your Clinician, describing your condition /

diagnosis, and confirming the medical need for the treatment(s). The letter /

report must clearly state why the treatment received will be / was needed.

For S2 applications:

1) The clinician’s letter / report must be from a UK NHS Consultant, on NHS

letterhead, and must support the treatment(s) being carried out in the

proposed country.

2) We also require written confirmation from the provider of: the agreed

treatment(s), treatment dates and estimated costs.

For Directive applications: The letter / report must be from an EEA Clinician

e.g. Consultant / GP (which includes a UK Clinician).

If the letter / report is provided by a Clinician from another EEA country, please

ensure this is in English or that an English translation is provided. You may

provide an accurate translation yourself, but please sign and date.

10. EEA application form (04 /15)

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What are / were the specific DATE(S) for the treatment(s) abroad?

(complete where applicable)

In-patient stays

(i.e. overnight stays

in hospital)

Day case

appointments (e.g.

day case surgery)

Out-patient

appointments (e.g.

clinics / check-ups /

consultations)

Other

appointments

(e.g. physiotherapy)

Diagnostics tests

(e.g. Blood tests /

scans)

Equipment /

Appliances issued

(e.g. walking aids,

hearing aids)

Medication Name

Type (e.g.

Strength

Quantity (e.g.

tablets, gel,

(e.g. 50mg)

1 x box 50

cream, liquid)

tablets, 1 x

100ml bottle)

Drugs / Medication

paid for

Other, please

specify

Are you applying before treatment?

Yes

If Yes go to (f), below, if No go to (g)

What are the estimated costs of the treatment?

10. EEA application form (04 /15)

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"Funding for Treatment in the European Economic Area (Eea) Application Form" - United Kingdom

Download "Funding for Treatment in the European Economic Area (Eea) Application Form" - United Kingdom

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