 Application Form - United Kingdom Download Pdf){kind=small}
1
2
3
4
5
6
7
8
9
10FUNDING 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)
Page 1 of 10
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)
Page 1 of 10
Part 1: Application Route
Treatment
On what basis is the treatment being provided?
Private system
or
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
No
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)
10. EEA application form (04 /15)
Page 2 of 10
Are you exempt from any
No
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)
Page 3 of 10
Part 4: Treatment Details
(in relation to this application)
a)
What is the DIAGNOSED medical condition for which you have received /
are planning to receive treatment(s) abroad?
b)
Describe the TREATMENT(S) you have received / are planning to receive
abroad.
c)
Is a Clinician’s letter / report attached:
Yes
No
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)
Page 4 of 10
d)
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
e)
Are you applying before treatment?
Yes
No
If Yes go to (f), below, if No go to (g)
f)
What are the estimated costs of the treatment?
10. EEA application form (04 /15)
Page 5 of 10
 Application Form - United Kingdom.&description=Fill out, print and use this and thousands of other free templates at templateroller.com.&screenshot=https://data.templateroller.com/pdf_docs_html/6/64/6418/funding-treatment-in-the-european-economic-area-eea-application-form_big.png&pubid=ra-5bab7ed006800266&ct=1)
 Application For...&via=templateroller&screenshot=https://data.templateroller.com/pdf_docs_html/6/64/6418/funding-treatment-in-the-european-economic-area-eea-application-form_big.png&pubid=ra-5bab7ed006800266&ct=1)
 Application Form - United Kingdom.&description=Fill out, print and use this and thousands of other free templates at templateroller.com.&screenshot=https://data.templateroller.com/pdf_docs_html/6/64/6418/funding-treatment-in-the-european-economic-area-eea-application-form_big.png&pubid=ra-5bab7ed006800266&ct=1)
 Application Form - United Kingdom.&description=Fill out, print and use this and thousands of other free templates at templateroller.com.&screenshot=https://data.templateroller.com/pdf_docs_html/6/64/6418/funding-treatment-in-the-european-economic-area-eea-application-form_big.png&pubid=ra-5bab7ed006800266&ct=1)
 Application Form - United Kingdom.&description=Fill out, print and use this and thousands of other free templates at templateroller.com.&screenshot=https://data.templateroller.com/pdf_docs_html/6/64/6418/funding-treatment-in-the-european-economic-area-eea-application-form_big.png&pubid=ra-5bab7ed006800266&ct=1)
 Application Form - United Kingdom.&description=Fill out, print and use this and thousands of other free templates at templateroller.com.&screenshot=https://data.templateroller.com/pdf_docs_html/6/64/6418/funding-treatment-in-the-european-economic-area-eea-application-form_big.png&pubid=ra-5bab7ed006800266&ct=1)