GP Application form for Procedures of Limited Clinical Value/Effectiveness
(POLCV/E) Prior Approval and Individual Funding Request (IFR)
2013/14
IMPORTANT
Before completing this application form, it is essential that you are aware of the eligibility criteria for the
treatment requested. Please refer to the following policies to confirm whether the treatment you are
requesting requires prior approval, and if so what specific information is needed in order for a funding
decision to be made:
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
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For patients registered with GPs in Waltham Forest, Newham, City and Hackney and Tower
Hamlets please refer to the WELC Procedures of Limited Clinical Value (POLCV) policy.
For patients registered with GPs in Barking and Dagenham, Havering and Redbridge please refer to
the BHR Procedures of Limited Clinical Value (POLCV) policy.
For patients registered with GPs in Barnet, Camden, Enfield, Haringey or Islington please refer to
the NCL Procedures of Limited Clinical Effectiveness (POLCE) policy.
These publications and the Clinical Commissioning Group (CCG) IFR policy should be available on your
CCG website, and should inform completion of this form. Please contact the IFR Team on 020 3688 1290 if
you have any queries, or if you require help completing this form.
Information Governance Statement
All Individual Funding Requests (IFR) may be reviewed by the Clinical Commissioning Group (CCG) as the
statutory body responsible for funding decisions. This application form and any other supporting information
supplied may therefore be shared with the CCG or other trusted organisations legitimately acting on behalf
of the CCG. Personal information may be retained only for the purposes of this IFR and, in some cases,
may be used for invoicing and payment reconciliation. Anonymised information may also be shared as part
of CCG reporting processes.
PLEASE SIGN OR TICK BELOW TO INDICATE THAT YOU:
1. Have discussed the Information Governance Statement with your patient and that they give their
consent for information about their case to be used to process their application in accordance with the
provisions of that statement.
2. Will take full responsibility for informing the patient about the IFR process including informing them
of the funding decision and their right of Appeal (if necessary).
Please tick 
Applicant’s signature
Signed by: ……………………………………………..…….. Date signed: ….……/…..……/..…….
Print name: …………………………………………………..
All forms must be signed by the NHS Practitioner (unsigned forms will not be accepted)
1
GP Individual Funding Request Application Form 2013/14 (December)

Please ensure all relevant boxes are complete. Incomplete forms will be returned.
Procedure requested:
Indication:
Contact Information:
Date of application
1. Applicant details
Name
Designation
Tel
Email – please
provide secure
nhs.net address for
all related
correspondence
NOTE: only nhs.net addresses are acceptable for
confidentiality reasons
GP Practice
GP Practice postcode
GP Practice code
CCG
2. Patient details
Patient initials:
Patient NHS Number:
DoB:
Male / Female
3. Referral Details
Speciality referred to:
Please give details of the Name & address of
organisation that will
Clinician & provider
provide the requested
referred to:
treatment.
NOTE: Please read carefully the next sections on how to proceed with your funding application as
incomplete information will delay the decision process.
Please do not include any patient identifiable data from this point forward in the application (Name, initials,
DoB, age, gender etc.)
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GP Individual Funding Request Application Form 2013/14 (December)
Instructions:
Section A should be used for POLCV/E Prior approval applications where the patient meets the eligibility
criteria outlined in the corresponding policy.
Section B should be used for IFR applications, including applications for POLCV/E listed treatments where
the patient does not meet the eligibility criteria.
SECTION A POLCV/E Applications ONLY
Category of intervention
Referring to the POLCV/E policy
please state which POLCV/E
treatment the application is for
(e.g. Breast reduction, scar
revision, abdominoplasty etc.)
Reading from the POLCV/E policy, please state how the patient
meets all the relevant inclusion criteria for the requested
treatment?
Please use standardised scores and measures as far as possible e.g.
3cm rather than “large”;
BMI 35 rather than “overweight”
A Visual Analogue Scale score rather than “lot of pain” etc.
Additional Information
Please describe any other
relevant clinical factors which
might support this application.
Please attach all relevant
information e.g. referral letters
from other clinicians etc.
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GP Individual Funding Request Application Form 2013/14 (December)
Section B – IFR Applications and POLCV/E applications where
patient does not meet eligibility criteria
Previous treatment history
(e.g. please list standard
treatments the patient has already
received for this condition)
Any other relevant comorbidities
Preferred Provider
(Is there a local NHS provider?)
Cost of treatment if known
Clinical Effectiveness
Strong
Medium
Please indicate how strong you
think the published evidence base
is for this intervention for this
condition
Exceptionality
How many patients with this condition would you expect an
average GP practice to see each year?
Exceptionality
Please describe any relevant
clinical factors which make this
patient’s case exceptional.
Please address the following
questions.
How is this patient is:
1. Clinically different to the general
population of other patients with
the same condition?
2. Likely to gain a significantly
greater health benefit from the
intervention than might be
expected for the average
patient with the condition?
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Weak
Don’t Know
GP Individual Funding Request Application Form 2013/14 (December)
Impact of condition/ treatment
Please describe how this condition
impacts on the patient’s daily living
and the expected improvement this
intervention will provide.
Individual Funding Request (IFR) Application Forms
should be returned
by Post:
IFR
NHS North and East London
Commissioning Support Unit
2nd Floor
Clifton House
75-77 Worship Street
London
EC2A 2DU
by Confidential Email:
Barking and Dagenham
nelcsubhr-ifr@nhs.net
Havering
Redbridge
nelcsuwelc-ifr@nhs.net
ncl.ifr@nhs.net
Contact the IFR team by telephone on:
020 3688 1290
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Waltham Forest
Newham
Tower Hamlets
City and Hackney
Barnet
Camden
Enfield
Haringey
Islington
GP Individual Funding Request Application Form 2013/14 (December)
GUIDANCE NOTES FOR CLINICIANS COMPLETING THIS IFR FORM
IFR Policy and further information
The IFR Policy and other policy documents are available from the IFR team, please contact the team on the
relevant email on page 5.
Before submitting an IFR, please check that this is the correct process. IFRs can be submitted by an NHS
consultant, a GP or dental practitioner, or an equivalent autonomous practitioner where he/she will be responsible
for administering the treatment. The requesting clinician is responsible for providing all supporting information and
evidence.
Information Governance and patient consent
Providing either a signature or tick box validates this request and indicates that you have discussed the
request with the patient, and that the patient has given consent to the submission. If this section is left
incomplete the form cannot be accepted, and we will inform you of this accordingly.
Details of patient and clinician submitting the request
It is essential that you please provide full contact details including an nhs.net email address, to enable us to easily
communicate with you while this case is being processed, and to inform you of the final outcome.
We must be able to identify the patient; provision of the patient’s NHS number is also essential. Please note that
patient details will not be available to the Panel to ensure anonymity. Please help the IFR Team by not referring to
the patient name or initials within the form – the only section which should contain patient demographic details is
page 2, which will be anonymised for Panel.
Diagnosis and the patient’s current condition/ Intervention for which funding is requested
The fullest possible information will help the Panel make a decision. Please ensure all relevant sections are
completed depending on the type of intervention.
Statement of clinical exceptionality
Clear evidence of patient exceptionality is essential in order to enable the IFR Panel to reach a funding decision.
Please state as clearly as possible, with reference to the existing policy if relevant, why this patient should be
treated as an exception. Evidence must be submitted to demonstrate how this patient’s clinical condition is
significantly different to other patients with a similar condition, and in addition how this patient is likely to gain a
greater health benefit compared to others in the cohort of similar patients.
The IFR Team aims to deal with all applications in a timely manner. A funding outcome can only be reached where
sufficient information is available to inform the decision. Urgency will be evaluated on the basis of clinical need.
Please contact the IFR Team on 020 3688 1290 for further information or clarification.
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