APPLICATION FOR PRIOR APPROVAL FOR FUNDING
Desensitizing Light Therapy in the Management
of Severe Polymorphic Light Eruption
STRICTLY PRIVATE AND CONFIDENTIAL
PART A: THIS PAGE MUST BE COMPLETED FOR ALL REQUESTS
PATIENT INFORMATION
Does this case need to be
reviewed urgently due to
clinical need?
If yes, please explain
(An urgent request is one which requires urgent consideration and a decision
YES because the patient faces a substantial risk of significant harm or death if a
NO
decision is not made before the next scheduled monthly meeting of the IFR
Panel. What is the window of opportunity and the timescale required for
optimum treatment?)
Name
Male
Female
Address
Post Code
Date of Birth
NHS Number
Referrer’s Details (GP/Consultant/Clinician):
Name
Address
Post Code
Telephone
Email
GP Details (if not referrer):
Name
Practice
By submitting this form you confirm that the information provided is, to the best of your knowledge, true and
complete and you confirm (unless otherwise stated in the box below) that you have:






Discussed all alternatives to this intervention with the patient.
Had a conversation with the patient about the most significant benefits and risks of this intervention.
Advised the patient that NHS Decision Making Aids are available online should the patient wish to access
them at http://sdm.rightcare.nhs.uk/pda/
Informed the patient that this intervention is only funded where criteria are met or exceptionality
demonstrated.
Checked that the patient is happy to receive postal correspondence concerning their application.
Discussed with the patient whether any additional communication requirements (e.g. different language,
format or limited capacity) are needed (please specify requirements in the box below).
Additional Information:
I understand that it is a legal requirement for fully informed consent to be obtained from the patient (or a legitimate
representative of the patient) prior to disclosure of their personal details for the purpose of a panel/IFR team to
decide whether this application will be accepted and treatment funded. By submitting this form I confirm that the
patient/representative has been informed of the details that will be shared for the aforementioned purpose and
consent has been given.
Signed Referrer:
………………………………….….…………………
Date:……………………………………..
PART B: THIS PAGE MUST BE COMPLETED FOR ALL REQUESTS
If your patient does not meet the following criteria then please ALSO fill out Part C of this form outlining
the patient’s exceptionality. If the criteria are met you only need complete Parts A and B.
1. Has the diagnosis of polymorphic light eruption (PMLE) been confirmed by a consultant
dermatologist?
YES  NO 
AND
2. Is the PMLE judged as ‘severe’ i.e. the patient has an extensive, itchy rash for most of the
UK summer?
YES  NO 
AND
3. Are the symptoms from PMLE rash causing severe functional impairment*?
* Significant functional impairment is defined by the BNSSG Health Community as:
- Symptoms preventing the patient fulfilling routine work or educational responsibilities
- Symptoms preventing the patient carrying out routine domestic or carer activities
YES  NO 
AND
4. Have the symptoms remained severe despite comprehensive use of prevention, first and
second line treatments? i.e.:

The patient is using protective clothing and broad spectrum sun protection Factor
30+ semi-opaque sunscreen frequently applied to all uncovered skin

The patient has been advised and tried gradually increasing exposure to sunlight
without relief

The patient has tried drug therapies for PMLE (topical steroids, or short course
systemic steroids for bad attacks if occurring once or twice per year)
YES  NO 
AND
5. Has a consultant dermatologist assessed light therapy as likely to significantly improve the
patient’s quality of life and functional impairments due to PMLE?
YES  NO 
Please enclose relevant correspondence.
Please provide evidence below to support the information you have provided, particularly which
conservative treatment methods have been unsuccessful.
Without evidence this application will be rejected.
Supporting Information - You may provide photographs if appropriate as supporting evidence.
What is the patient unable to do as a
result of their condition?
Is the patient unable to fulfil any
work/study/carer essential activities and
if so to what extent?
Is the patient unable to carry out
essential domestic activities such as
cooking, washing etc?
Supporting Information
Please document the evidence you
are enclosing along with any other
information that you feel is relevant
PLEASE SEND THIS FORM TO THE CCG IF THE ABOVE CRITERIA ARE FULLY MET AND
EVIDENCED. IF NOT, PLEASE GO ON TO COMPLETE PART C.
PART C: INDIVIDUAL FUNDING REQUEST
ONLY COMPLETE IF PATIENT DOES NOT MEET THE CRITERIA IN PART B
Exceptionality
Please note that not meeting the criteria is not in itself exceptional. The sections
below must be completed, clearly outlining a comprehensive and thorough case
for the exceptionality of your patient, to enable the IFR Panel to reach a funding
decision.
Explain why the
patient is significantly
different to the general
population of patients
with the condition in
question
Explain why the
patient is likely to
benefit more from the
intervention than might
normally be expected
for patients with that
condition
Brief and relevant health history, including patient’s current health status and any other co-morbidities,
health issues and current medication.
Clinical History
relevant to the case
What treatments has
the patient tried? Is
this patient unable to
tolerate the usual
care? What services
has the patient been
referred to?
The patient is welcome to provide a statement and photographs to support this application if they wish.
The completed form should be sent in confidence with any other supporting documents to:
North Somerset CCG:
Bristol CCG:
South Gloucestershire CCG:
Prior Approval Applications
Individual Funding Request Team Individual Funding Request Team
Referral Support Service
South Plaza,
Suite 15, Corum 2
Post Point 11,
Marlborough Street,
Corum Business Park,
Castlewood, Tickenham Road,
Bristol,
Warmley,
North Somerset, BS21 9BH
BS1 3NX
Bristol, BS30 8FJ
rss@nhs.net
ifrbristol@nhs.net
ifrsglos@nhs.net
Individual Funding Applications
Individual Funding Request Team
Castlewood, Tickenham Road,
North Somerset, BS21 9BH
ifrnsomerset@nhs.net
In order to comply with information governance standards, emails containing identifiable patient data should only
be sent securely, i.e. from an nhs.net account
Bristol
CATEGORY
Prior Approval
VERSION
1516.1
North Somerset
CATEGORY
Prior Approval
VERSION
1516.1
South Gloucestershire
CATEGORY
Prior Approval
VERSION
1516.1