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S2 EEA HSC Application Form PDFPage 1 of 7
UK S2 PLANNED TREATMENT APPLICATION FORM (NORTHERN IRELAND)
THIS S2 FORM IS FOR UK (NORTHERN IRELAND) RESIDENTS, WHO ARE WANTING TREATMENT IN AN EU (NON-UK) COUNTRY. IF TREATMENT IS REQUESTED IN NORWAY, ICELAND, LIECHTENSTEIN OR SWITZERLAND, PLEASE CONTACT england.europeanhealthcare@ nhs.net TO CONFIRM IF YOU ARE ELIGIBLE, BEFORE YOU APPLY. DO NOT USE THIS FORM IF YOU HAVE A UK ISSUED S1 AND LIVE IN ANOTHER EU (NON-UK) COUNTRY. THERE IS A SEPARATE FORM AND GUIDANCE FOR THIS. FIND OUT MORE ON THE NHS WEBSITE AT WWW.NHS.UK BY SEARCHING FOR ‘HEALTHCARE ABROAD’. THIS INCLUDES SUPPORTING GUIDANCE NOTES FOR THE S2 APPLICATION FORM. Please note: Health and Social Care Board in Northern Ireland can only process applications for people ordinarily resident in Northern Ireland and legally entitled to the full range of Health and Social Care services. • Applications must be authorised by the Health & Social Care Board (HSCB) before treatment. • The treatment must be provided in the state healthcare system of the other country.
• It is very important that you check whether the provider will accept an S2 form for the treatment(s)
you are applying for. • Applications for maternity S2 funding must be made directly https://www.nhs.uk/using-the-
nhs/healthcare-abroad/going-abroad-for-treatment/giving-birth-outside-the-uk/ and not to this team (www.nhs.uk for further information).
• S2 applications cannot cover experimental treatments or drug trials. • If the treatment you are requesting is available locally you must provide written confirmation from
your Northern Ireland Health and Social Care (NI HSC) Consultant that your wait for HSC (NI) treatment is clinically inappropriate.
NOTE:
Under the S2 route, the patient is taking individual responsibility for ensuring that the service they obtain is appropriate and safe within the laws of the country of treatment (not under UK legislation). The HSC, under this legislation, will not be formally commissioning services from providers abroad and therefore will not be liable for the outcome of the treatment provided.
The applicant is responsible for providing accurate and complete information with the application. This will form the basis of the decision making process. Incomplete applications will cause delay in processing your claim.
See guidance notes to help you complete this application form correctly.
Page 2 of 7
I can confirm that the planned treatment is in the state healthcare sector and treatment is planned in the following EU Country
EU Country: ______________________ I can confirm I am ordinarily resident in Northern Ireland and do not have a UK
issued S1.
Confirmation of the Applicant Are you (the applicant) also the patient? Yes No - also complete Parts 7&8
Part 2: Patient Details
Alternative address for correspondence (if applicable)
GP Name / Registered GP practice (this must be the GP you were registered with at the time of the treatment you are applying for):
GP address (inc. postcode)
Page 3 of 7
Part 3: EU Treating Consultant / Provider Details
Please provide details of the main establishment(s) where you want to receive treated in Europe (If this involves more than one establishment, please provide details on a separate sheet.)
Treating Consultant name
Name of establishment
a.
What is the DIAGNOSED medical condition for which the patient has received / is planning to receive treatment(s) abroad?
b.
Describe the TREATMENT(S) the patient is planning to receive abroad
c.
What are the specific DATE(S) for the treatment(s) abroad (where applicable)?
In-patient stays (i.e. overnight stays in hospital)
Out-patient appointments (e.g. clinics / reviews)
Day-case procedures (admitted and discharged on the same day)
S2 (E112) Application Form at 25/01/2021
Page 4 of 7
Diagnostics tests (e.g. Blood tests / scans)
Equipment / Appliances issued (e.g. walking aids, hearing aids)
d.
Is a Consultant’s letter / report attached: Yes No A letter / report must be attached from the patient’s Consultant, describing the patient’s condition / diagnosis, and confirming the medical need for the treatment(s). S2 applications: 1. The Consultant’s letter / report must be from a Northern Ireland HSC Consultant, on HSC Trust
letterhead, and must support the treatment(s) being carried out in the proposed country. 2. If the treatment is available within Northern Ireland we require confirmation from your local NHS
Consultant that the waiting time is clinically inappropriate based on his/her objective assessment of your individual clinical needs.
3. We also require written confirmation from the provider of: the agreed treatment(s), treatment dates and estimated costs.
4. Confirmation that the treatment is not experimental or a drug trial.
e.
What treatments (if any) are you already receiving / have received, for this condition under the HSC (NI)?
f. Provide the name of your Northern Ireland treating Consultant and Health & Social Care Trust
g. Is the treatment requested outside Northern Ireland available under the Health & Social Care System (NI)?
h.
Have you applied to the HSCB (NI) for this treatment before? If so, was it approved?
S2 (E112) Application Form at 25/01/2021
Page 5 of 7
Funding Approved: Yes No
Funding Approved: If yes, provide further details, including dates / reference numbers: If no, provide the reason why funding was not approved:
h. Are you expecting to receive follow-up treatment from the HSC (NI) when you return?
Yes No
Page 6 of 7
Part 6: Declaration by the Applicant
I declare that all the information I have provided is correct and complete. I understand and accept that if I knowingly withhold information or provide false or misleading information, I may be liable to prosecution and/or civil proceedings. I consent to the disclosure of all information relating to my application to and by HSCB Northern Ireland, the Department of Health, the Business Services Organisation, the NHSBSA, NHS counter Fraud Authority, Electoral Office, Home Office, Passport Office, and other HSC (NI) bodies, necessary for the processing and verification of this claim and the investigation, prevention, detection and prosecution of fraud.
I understand that the HSCB NI is not liable for the care received abroad when funded the S2
By ticking the following box, I confirm that the patient is normally resident in Northern Ireland and entitled to receive Health and Social Care (HSC) services:
I declare that I am the patient / I am acting with the consent of the patient / I am legally empowered to act on behalf of the patient (delete as appropriate)
Name of applicant
Signature of applicant
Are you the Applicant also the patient?
Yes
Part 8: Declaration by the Applicant (when not the patient)
I declare that I am applying with the consent of the patient/ I am legally empowered to act on behalf of the patient (delete as appropriate).
Name of Applicant Relationship to Applicant
Signature Email address
Part 9: Declaration/Consent by the Patient when not the Applicant
I hereby give permission for the person identified as the Applicant in Part 8 of this form to make this application on my behalf. I understand that the HSC (NI) is not liable for the care received abroad when funded under the S2 route.
Name of patient
Signature of patient
Page 7 of 7
Security Question and Answer: Q: _______________________ A:________________________ (please provide for phone call ID verification)
UK S2 disclaimer This scheme only covers the cost of planned treatment, as agreed with the UK Government. The S2 certificate is not an alternative to comprehensive medical or travel insurance, which may be required to cover the costs of any treatment which an S2 certificate will not specifically authorise. Please keep up to date with information on available funding options on the NHS website at www.nhs.uk by searching for ‘healthcare abroad’. Signature of applicant confirming you have read and understood the above disclaimer: Signature: _________________________ Date: _______________________ Please note that this application will not be processed until all of the necessary supporting information has been received. Incomplete applications will be put on hold and not processed until complete.
Please send your completed form and accompanying documents to the following address:
National Contact Point (NI) Patient Travel and Reimbursement Team Health & Social Care Board 12/22 Linenhall Street Belfast, BT2 8BS Or email: [email protected] Please note: It can take up to 20 working days for a fully completed application to be processed and a decision to be made.
UK S2 PLANNED TREATMENT APPLICATION FORM (NORTHERN IRELAND)
THIS S2 FORM IS FOR UK (NORTHERN IRELAND) RESIDENTS, WHO ARE WANTING TREATMENT IN AN EU (NON-UK) COUNTRY. IF TREATMENT IS REQUESTED IN NORWAY, ICELAND, LIECHTENSTEIN OR SWITZERLAND, PLEASE CONTACT england.europeanhealthcare@ nhs.net TO CONFIRM IF YOU ARE ELIGIBLE, BEFORE YOU APPLY. DO NOT USE THIS FORM IF YOU HAVE A UK ISSUED S1 AND LIVE IN ANOTHER EU (NON-UK) COUNTRY. THERE IS A SEPARATE FORM AND GUIDANCE FOR THIS. FIND OUT MORE ON THE NHS WEBSITE AT WWW.NHS.UK BY SEARCHING FOR ‘HEALTHCARE ABROAD’. THIS INCLUDES SUPPORTING GUIDANCE NOTES FOR THE S2 APPLICATION FORM. Please note: Health and Social Care Board in Northern Ireland can only process applications for people ordinarily resident in Northern Ireland and legally entitled to the full range of Health and Social Care services. • Applications must be authorised by the Health & Social Care Board (HSCB) before treatment. • The treatment must be provided in the state healthcare system of the other country.
• It is very important that you check whether the provider will accept an S2 form for the treatment(s)
you are applying for. • Applications for maternity S2 funding must be made directly https://www.nhs.uk/using-the-
nhs/healthcare-abroad/going-abroad-for-treatment/giving-birth-outside-the-uk/ and not to this team (www.nhs.uk for further information).
• S2 applications cannot cover experimental treatments or drug trials. • If the treatment you are requesting is available locally you must provide written confirmation from
your Northern Ireland Health and Social Care (NI HSC) Consultant that your wait for HSC (NI) treatment is clinically inappropriate.
NOTE:
Under the S2 route, the patient is taking individual responsibility for ensuring that the service they obtain is appropriate and safe within the laws of the country of treatment (not under UK legislation). The HSC, under this legislation, will not be formally commissioning services from providers abroad and therefore will not be liable for the outcome of the treatment provided.
The applicant is responsible for providing accurate and complete information with the application. This will form the basis of the decision making process. Incomplete applications will cause delay in processing your claim.
See guidance notes to help you complete this application form correctly.
Page 2 of 7
I can confirm that the planned treatment is in the state healthcare sector and treatment is planned in the following EU Country
EU Country: ______________________ I can confirm I am ordinarily resident in Northern Ireland and do not have a UK
issued S1.
Confirmation of the Applicant Are you (the applicant) also the patient? Yes No - also complete Parts 7&8
Part 2: Patient Details
Alternative address for correspondence (if applicable)
GP Name / Registered GP practice (this must be the GP you were registered with at the time of the treatment you are applying for):
GP address (inc. postcode)
Page 3 of 7
Part 3: EU Treating Consultant / Provider Details
Please provide details of the main establishment(s) where you want to receive treated in Europe (If this involves more than one establishment, please provide details on a separate sheet.)
Treating Consultant name
Name of establishment
a.
What is the DIAGNOSED medical condition for which the patient has received / is planning to receive treatment(s) abroad?
b.
Describe the TREATMENT(S) the patient is planning to receive abroad
c.
What are the specific DATE(S) for the treatment(s) abroad (where applicable)?
In-patient stays (i.e. overnight stays in hospital)
Out-patient appointments (e.g. clinics / reviews)
Day-case procedures (admitted and discharged on the same day)
S2 (E112) Application Form at 25/01/2021
Page 4 of 7
Diagnostics tests (e.g. Blood tests / scans)
Equipment / Appliances issued (e.g. walking aids, hearing aids)
d.
Is a Consultant’s letter / report attached: Yes No A letter / report must be attached from the patient’s Consultant, describing the patient’s condition / diagnosis, and confirming the medical need for the treatment(s). S2 applications: 1. The Consultant’s letter / report must be from a Northern Ireland HSC Consultant, on HSC Trust
letterhead, and must support the treatment(s) being carried out in the proposed country. 2. If the treatment is available within Northern Ireland we require confirmation from your local NHS
Consultant that the waiting time is clinically inappropriate based on his/her objective assessment of your individual clinical needs.
3. We also require written confirmation from the provider of: the agreed treatment(s), treatment dates and estimated costs.
4. Confirmation that the treatment is not experimental or a drug trial.
e.
What treatments (if any) are you already receiving / have received, for this condition under the HSC (NI)?
f. Provide the name of your Northern Ireland treating Consultant and Health & Social Care Trust
g. Is the treatment requested outside Northern Ireland available under the Health & Social Care System (NI)?
h.
Have you applied to the HSCB (NI) for this treatment before? If so, was it approved?
S2 (E112) Application Form at 25/01/2021
Page 5 of 7
Funding Approved: Yes No
Funding Approved: If yes, provide further details, including dates / reference numbers: If no, provide the reason why funding was not approved:
h. Are you expecting to receive follow-up treatment from the HSC (NI) when you return?
Yes No
Page 6 of 7
Part 6: Declaration by the Applicant
I declare that all the information I have provided is correct and complete. I understand and accept that if I knowingly withhold information or provide false or misleading information, I may be liable to prosecution and/or civil proceedings. I consent to the disclosure of all information relating to my application to and by HSCB Northern Ireland, the Department of Health, the Business Services Organisation, the NHSBSA, NHS counter Fraud Authority, Electoral Office, Home Office, Passport Office, and other HSC (NI) bodies, necessary for the processing and verification of this claim and the investigation, prevention, detection and prosecution of fraud.
I understand that the HSCB NI is not liable for the care received abroad when funded the S2
By ticking the following box, I confirm that the patient is normally resident in Northern Ireland and entitled to receive Health and Social Care (HSC) services:
I declare that I am the patient / I am acting with the consent of the patient / I am legally empowered to act on behalf of the patient (delete as appropriate)
Name of applicant
Signature of applicant
Are you the Applicant also the patient?
Yes
Part 8: Declaration by the Applicant (when not the patient)
I declare that I am applying with the consent of the patient/ I am legally empowered to act on behalf of the patient (delete as appropriate).
Name of Applicant Relationship to Applicant
Signature Email address
Part 9: Declaration/Consent by the Patient when not the Applicant
I hereby give permission for the person identified as the Applicant in Part 8 of this form to make this application on my behalf. I understand that the HSC (NI) is not liable for the care received abroad when funded under the S2 route.
Name of patient
Signature of patient
Page 7 of 7
Security Question and Answer: Q: _______________________ A:________________________ (please provide for phone call ID verification)
UK S2 disclaimer This scheme only covers the cost of planned treatment, as agreed with the UK Government. The S2 certificate is not an alternative to comprehensive medical or travel insurance, which may be required to cover the costs of any treatment which an S2 certificate will not specifically authorise. Please keep up to date with information on available funding options on the NHS website at www.nhs.uk by searching for ‘healthcare abroad’. Signature of applicant confirming you have read and understood the above disclaimer: Signature: _________________________ Date: _______________________ Please note that this application will not be processed until all of the necessary supporting information has been received. Incomplete applications will be put on hold and not processed until complete.
Please send your completed form and accompanying documents to the following address:
National Contact Point (NI) Patient Travel and Reimbursement Team Health & Social Care Board 12/22 Linenhall Street Belfast, BT2 8BS Or email: [email protected] Please note: It can take up to 20 working days for a fully completed application to be processed and a decision to be made.