Additional treatment funding
request form
Please complete all sections of this form to enable us to assess eligibility for Bupa
funding of additional treatment sessions for your Bupa patient. Without the information
requested, assessment and authorisation for funding may be delayed.
We would be grateful if the information you provide is typed and not handwritten.
Please return completed forms to the Therapies Management team:
Fax: 0161 254 5808 E-Mail: tmtsm@bupa.com (Secure Access is required for e-mails)
1. About the patient
Name:
Bupa membership number:
Date of birth:
Postcode:
Contact number:
2. Therapist Details
Name:
Profession:
Provider number:
Phone number:
3. Diagnosis
Please provide details of diagnosis, and date of onset, for all of your Bupa patient’s
conditions:
Please provide subjective and objective findings eg current symptoms, VAS, ROM,
palpation, response to date? (if a spinal condition please provide details of neurological
assessment findings)
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Additional treatment funding
request form
Please give the prognosis of each of the conditions.
Outcome measure used (previous score and current score) e.g. PSFS:
4. Treatment plan
Please summarise treatment to date and response:
Number of sessions so far and treatment dates:
Additional sessions requested:
Please provide the proposed treatment plan eg, expected duration, self management
strategies and what you expect the treatment sessions to include.
Please list all analgesia patient is currently taking including frequency and dosage.
Are there other factors influencing the treatment progression (eg psychosocial, comorbidities)?
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Additional treatment funding
request form
5. Referral
Who referred this patient to you and do you have a copy of the referral or consultant
referral/protocol if needed?
Comments: please provide any other supporting information, such as consultant
protocols, investigation dates/findings, consultant appointments
Bupa may verify the information submitted in this form against a copy of the patient’s
full medical notes, which may be requested from you and their GP in order to confirm
eligibility for funding.
Please provide all relevant information to enable us to assess whether the treatment
requested by your Bupa patient is eligible for Bupa funding.
Please do not send patient identifiable data via email, as this is not necessarily a
secure method.
I confirm that the information in this form is accurate to the best of my
knowledge. I certify that the patient (or their representative) has given
permission for this information to be provided to Bupa for the purposes
described within this form.
Therapist signature:
Date:
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