Embed Size (px)
Citation preview
1 Updated November 2017
Please complete this form to request funding for all Bupa patients who need more sessions of therapy than we’ve initially pre-authorised. It will mean we have all the information we need to see whether the patient’s policy covers any additional sessions of therapy.
We initially pre-authorise five sessions of therapy (except post-operative sessions where we use best practice guidelines to determine the number of sessions on the initial pre-authorisation and you can find these on Providers Online). However we’ll consider funding more where it is clinically necessary and covered by the customers health insurance policy.
Our health insurance policies cover evidence based, clinically appropriate treatment of acute conditions which is expected to quickly restore the patient to their previous state of health. You can find out more at: www.bupa.co.uk/important-points-about-your-cover.
We recommend that you submit this form as soon as you know that the patient needs more sessions than we’ve originally authorised to avoid delaying future treatment. We’ll let the patient know and update the number of sessions on Providers Online for you within three working days of receiving your completed form.
Please send us your completed form by secure email* to: [email protected] or by fax to: 0161 254 5808. *Information you send to this email address may not be secure unless you send us your email through Egress Switch. To sign up for a free Egress Switch account, go to https://switch.egress.com/ui/learn.
For any questions, please call 0345 600 0541 between 8am and 8pm Monday to Friday, and 8am and 4pm on Saturdays (we may record or monitor our calls).
Patient information Patient’s name: Date of birth:
Bupa Membership Number: Phone number:
Therapist information Therapist’s name: Bupa Provider Number:
Diagnosis What’s the patient’s diagnosis? (Please explain all conditions being treated and the investigations that support those diagnoses)
Assessment Initial assessment Current assessment
Subjective markers (please list for all conditions being treated, eg Visual Analogue Scale, functional limitation etc)
Funding request: Further therapy treatment
Funding request: Further therapy treatment
2 Funding request: Further therapy treatment
Initial assessment Current assessment
Objective markers (please list for all conditions being treated, eg range of movement etc)
Initial score Current score
Outcome Measures (please list for all conditions being treated eg Patient Specific Functional Scale)
Treatment Treatment start date:
Please summarise the treatment to date and response:
Number of sessions to date:
Proposed treatment plan:
Number of additional sessions requested:
Please explain the clinical reason for further treatment, detailing best practice guidelines used.
Are there any other unrelated conditions which may affect recovery?
Declaration Please complete the section below to confirm that the information in this form is accurate to the best of your knowledge. We may request a copy of the patient’s full medical notes from you and their GP to confirm that the proposed treatment is covered by their health insurance scheme.
Therapist’s signature: Date:
