EIBSS SCM Application Form: Guidance for Healthcare Professionals, Summaries of Business

Download EIBSS SCM Application Form: Guidance for Healthcare Professionals and more Summaries Business in PDF only on Docsity! 1 England Infected Blood Support Scheme (EIBSS) Special Category Mechanism (SCM) application form To make an application to the SCM, you must: • already have made a successful hepatitis C stage 1 payment application to EIBSS; and • have one of the specific hepatitis C associated conditions listed in Section 5 or believe that your hepatitis C infection, or its treatment, complications, or a condition caused by the infection is affecting your ability to carry out everyday activities. This SCM process allows stage 1 beneficiaries to apply for the higher annual payments, equivalent to HIV and hepatitis C stage 2 annual payments. If you have already successfully applied to the Scheme and have been diagnosed with advanced cirrhosis, primary liver cancer, have been offered or are in receipt of a liver transplant, have B-cell non-Hodgkin’s Lymphoma or have Type 2 or 3 Cryoglobulinaemia (only accompanied by membranoproliferative glomerulonephritis (MPGN)), you will already be receiving hepatitis C stage 2 annual payments and so this process does not apply to you. Please speak to the NHS Business Services Authority (NHSBSA) for further advice about this if you are unsure. If you find you do not qualify for stage 2 payments, you may complete this application form. To complete this application form, it is important that you contact your hospital consultant or viral hepatitis nurse to discuss the application and the accompanying guidance notes. If you are not under the care of a hospital doctor or viral hepatitis nurse, please contact the NHS Business Services Authority (NHSBSA) who will be able to advise further. Your GP may be an acceptable alternative, but we would prefer the evidence to come from the hospital service treating you. Please note that you and your doctor/nurse must complete: • Section 4 • Either Section 5 or Section 6 You also need to complete Sections 1 and 2 and your doctor/nurse must also complete Section 7. Notes to applicants EIBSS - Special Category Mechanism Form (V5) 07.2019 2 Please read these notes carefully before completing the form. How to complete the form You will need to contact your hospital consultant or viral hepatitis nurse to complete the form, as your application will need their medical evidence to confirm the associated condition or the impact the infection is having. Together you will need to complete, sign, and date the form before sending it to us. We would prefer the evidence to come from the hospital service treating you, however if you are not being seen by a hospital doctor or viral hepatitis nurse, your GP may be an acceptable alternative. Please contact the NHSBSA by telephone on 0300 330 1294, by email to [email protected], or in writing to: FREEPOST EIBSS (valid within the UK only) or to EIBSS, NHSBSA, Bridge House, 152 Pilgrim Street, Newcastle-upon-Tyne, NE1 6SN. who will be able to advise you about who could help you with this form. If you have to pay to obtain medical evidence at this stage, the NHSBSA will pay you back in full. Please complete: • The declaration at Section 4; and • either Section 5 or Section 6 (whichever of the two is the most appropriate to your situation). Section 4 contains declarations for you and your doctor/nurse to complete and sign. Please read everything carefully as a partially completed form may have to be returned to you and will delay the processing of your application. Complete Section 5 of the form if you have one of the diseases listed there. If the evidence confirms that you have one of the conditions listed at the start of Section 5, you will be successful in your application. You must: • sign and date the declaration at Section 4A; and • complete Section 5A. Your doctor (or viral hepatitis nurse) must: • sign and date the declaration at Section 4B; • complete Section 5B and provide supporting medical evidence; and • provide an overall clinical assessment at Section 7. Complete Section 6 with the help of your doctor or viral hepatitis nurse if you do not have any of the diseases listed in Section 5. You must: • sign and date the declaration at Section 4A; and • complete Section 6A. Your doctor (or viral hepatitis nurse) must: • sign and date the declaration at Section 4B; • complete Section 6B and provide supporting medical evidence; and • provide an overall clinical assessment at Section 7. 5 Title: Address (including postcode): First name: Last name: Date of birth: Mobile number: EIBSS reference number (if you already have one): Landline number: Marital/civil partnership status: We will ask you to supply relevant supporting evidence if you are applying on behalf of a recipient. For example, this may include a Power of Attorney or a signed letter from a GP. If you’re unsure what evidence to supply please contact us at [email protected] or on 0300 330 1294, or you can write to us at FREEPOST EIBSS (valid within the UK only) or at EIBSS, NHSBSA, Bridge House, 152 Pilgrim Street, Newcastle-upon-Tyne, NE1 6SN. Section 1 - Applicant’s details / / Postcode Please indicate your preferred method by which we may contact you with essential information about the Scheme by ticking the relevant box(es) below: I prefer to be contacted by: letter telephone email Please let us know if you need your letter in a specific format: If you are happy for us to write to you, where would you like us to send any letters?: My home address An alternative address (please provide below) If you have indicated that you are happy for us to contact you by telephone or email, please provide the details you’d like us to use here: Landline telephone number: Mobile telephone number: Email address: Section 2 - Contact preferences Postcode 6 By submitting this form to the NHSBSA, you confirm that you have read and understood the privacy notice at the end of this form. Your personal information will only be used by the NHSBSA on behalf of the Department of Health, to check your eligibility for a payment and to administer your application. In the event that you appeal a decision, your information may be disclosed to a panel of experts. Information about the NHSBSA’s privacy policy is available at www.nhsbsa.nhs.uk/our-policies/privacy. All personal information will be transferred and stored securely in compliance with Data Protection law. By submitting this form to a medical professional, you consent that your medical details necessary to evidence your application will be supplied to the NHSBSA for the purpose of administering your application. If your application is deemed to be ineligible, the Scheme will keep your application form on file for up to ten years so that it has a full historical record in the event that you lodge an appeal or if you reapply for a payment. If you have any questions regarding the use of your information, please contact the Scheme administrator, by telephone on 0300 330 1294, by email to [email protected], or in writing to: FREEPOST EIBSS (valid within the UK only) or to EIBSS, NHSBSA, Bridge House, 152 Pilgrim Street, Newcastle-upon-Tyne, NE1 6SN. Section 3 - Data Protection Declaration: I confirm that the information given in this application form is, to the best of my knowledge and belief, correct and complete. I understand and consent to the sharing of information relating to my medical condition with assigned expert group members of the NHS Business Services Authority for the purposes of applying for increased annual payments and with the NHS Counter Fraud Authority for the purposes of verification of this claim and the investigation, prevention, detection and prosecution of fraud. I understand that if I knowingly give false information, support will be stopped and I may be asked to return any financial support given to me as a result of this application and that I may be liable for prosecution and civil recovery proceedings. Signed: Date: Section 4A - Applicant Declaration (to be completed by you/your representative) / / 7 Declaration: By signing this form I confirm that the information contained within Sections 5 and/or 6 and 7 of the form is true to the best of my knowledge and belief and that if I knowingly authorise false information this may result in disciplinary action and I may be liable for prosecution. I consent to the disclosure of information from this form to and by the NHS Business Services Authority and NHS Counter Fraud Authority for the purpose of verification of this claim and for the investigation, prevention, detection and prosecution of fraud. Signed: Date: Identity and authority of the medical practitioner completing the relevant sections of the form Name of medical practitioner: Hospital: Job title: Address: Department: When did you last see the applicant? Telephone number: Mobile number: Email address: If Section 4B was completed by a viral hepatitis nurse, this box should be signed by a hospital consultant hepatologist to verify the information and evidence provided by the nurse. GP practice stamp: Section 4B - Medical Practitioner Declaration (to be completed by your doctor or viral hepatitis nurse) / / / / Postcode 10 Please say how substantial the impact of the above is on your ability to carry out day-to-day activities. Please give clear descriptions of how you are affected and examples, and how long you have been experiencing this. If you wish to add more information, please attach to the back of this application form. (Maximum word limit 500) Section 6B – To be completed by your doctor or viral hepatitis nurse Please confirm that, in your experience of the applicant, their hepatitis C infection (or its treatment or complications) is making it difficult for them to carry out regular daily activities as a result of mental health problems. Please state a) which mental health problems, b) how long these mental health problems have been going on for, and c) their expected duration. If your patient has been receiving treatment for mental health problems (e.g. medication, counselling, other therapies), then please provide any evidence you have on this. In your opinion, how likely is it that your patient’s mental health problems are attributable to their hepatitis C infection (or its treatment or effects)? (Tick one box) Not likely – explained by other causes Possible Highly likely Definite If you wish to add more information, please attach to the back of this application form. (Maximum word limit 500) 11 Please confirm that, in your experience of the applicant, their hepatitis C (or its treatment or complications) is making it difficult for them to carry out regular daily activities as a result of chronic fatigue. Please state how long this chronic fatigue has been going on for, and its expected duration. If your patient has been receiving treatment for fatigue (e.g. medication, counselling, other therapies), then please provide any evidence you have on this. In your opinion, how likely is it that your patient’s fatigue is attributable to their hepatitis C infection (or its treatment or effects)? (Tick one box) Not likely – explained by other causes Possible Highly likely Definite If you wish to add more information, please attach to the back of this application form. (Maximum word limit 500) 12 Overall clinical opinion Please confirm that, in your clinical judgement, it is likely that your patient’s hepatitis C infection, (or its treatment or complications) is having a substantial and long-term adverse impact on their ability to carry out daily activities. Please give an opinion on the following scale to say whether the difficulty in carrying out regular daily activities is likely to be attributable to the hepatitis C infection or its effects (tick one box) Not likely – explained by other causes Possible Highly likely Definite Clinical assessment (Maximum word limit 500) If you wish to add more information, please attach to the back of this application form. Section 7 - To be completed by your doctor or viral hepatitis nurse