Evidence Based Interventions and Clinical Standards Policy (EBICS) approval application form

Notes:
•	This form is to be used to apply for approval in line with the NCL Evidence Based Interventions and Clinical Standards Policy (formerly the PoLCE policy). The policy is available on the GP website: Evidence Based Interventions and Clinical Standards (EBICS) - North Central London GP Website (icb.nhs.uk)
•	Please complete and submit this form for prior approval before making your referral to Secondary Care. This form needs to be emailed to: HARCCG.HaringeyPoLCETriageService@nhs.net
•	Relevant supporting information such as clinic letters and a summary printout of the GP record should be attached wherever possible.
•	Some procedures in the NCL policy ask for a referral via the Individual Funding Request (IFR) process. The IFR form is available on the GP website: http://gp.haringeyccg.nhs.uk/services/individual-funding-request-ifr/7522 

Information Governance Statement
All EBICS requests 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 process 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 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 EBICS process including informing them of the funding decision and their right of Appeal (if necessary).

YES, I CONSENT                                                            NO, I DO NOT CONSENT 

Requesting clinician information 	
Referring GP name	Free Text Prompt      	Practice code	Organisation National Practice Code      	
Practice name and address	Organisation Name Organisation Full Address (single line)      	
Email:	Organisation E-mail Address      	Tel:	Organisation Telephone Number      	
Patient information	
Name:	Title Given Name Surname      	NHS No.	NHS Number      	
DOB (dd/mm/yyyy): 	Date of Birth      	Gender:	Gender(full)      	
EBICS criteria (type in boxes – expand as required)	
What procedure does this application refer to? Please refer to the NCL EBICS policy	     	
What is the condition for which this treatment is proposed?	     	
What are their symptoms? 	     	
What is the proposed treatment?	     	
How is the condition affecting the patient?	     	
What treatment has the patient had for this condition before and with what effect?	     	
What other medical conditions does the patient have? How, if at all, might they relate to the EBICS condition?	     	
Any other relevant factors or information?	     	
Request for:	

Assessment Only  
(EBICS application on the basis of requested approval for assessment only in Secondary Care, subject to a final EBICS application for approval for treatment submitted)	Treatment  Only  
(Patient has previously received an approved EBICS assessment only on first application and received first out-patient assessment & appointment in Secondary Care)	Assessment and Treatment  
(Subject to the EBICS application criteria met and approved within NCL policy)	

All data are handled and stored in accordance with Data Protection Regulations. I confirm that the patient has consented to their data being shared on a need to know basis with NHS staff. 		

Please email this form to: HARCCG.HaringeyPoLCETriageService@nhs.net