Funding Application for GLUTEN FREE FOODS

Patient NHS No.

Trust:
GP Name:
Patient Hospital No.
Name of Dietitian /GP Making Request:
GP code / Practice code:
Patient initials & DoB:
Dietitian / GP Contact Details:
GP Post code:

Please explain why this patient could be at risk of dietary neglect.

Only fully completed forms will be accepted for consideration by the CCG.

Please complete this form with as much detail as possible and send to mkccgpharmacy@nhs.net

Please provide the patient’s maximum units of gluten-free food allowable within MKCCG guidelines (based on Coeliac UK guidance). Please note that if approval is given it will only be for GF bread, flour and pasta.
Please confirm that the (please tick):

Patient will have an annual GP review and as part of that review an assessment will be made on whether there has been a change in circumstances which mean that the patient is no longer at risk of dietary neglect.

CCG will be informed if the patient is no longer considered at risk of dietary neglect and so no longer requires gluten-free food at NHS expense.

☐ Yes	☐ No
Dietitian / GP contact e-mail in case of CCG query (nhs.net address if available):

Dietitian / GP signature (electronic signature acceptable):

Date of application:

Milton Keynes Clinical Commissioning Group Gluten Free Food Supply Policy 2017

Milton Keynes Clinical Commissioning Group’s Governing Body has decided to stop providing gluten-free foods on the NHS unless there are specific circumstances whereby a patient could be at risk of dietary neglect.

Information for GPs or dietitians

If you think that your patient’s specific circumstances mean that they could be at risk of dietary neglect then you can request that their case is considered by MKCCG. You will need to complete this proforma and include as much information as possible so that the case can be fully reviewed by the team. An example of exceptionality may be a child whose carer would not be able to organise or financially cope with providing a GF diet. This request should be sent to mkccgpharmacy@nhs.net

2

LCCG: This form should be returned to Lutonnotification.proforma@nhs.net; Secure fax: 01582 511054, The Lodge, 4 George St West, Luton, LU1 2BJ. BCCG: This form should be returned to Christine Garrett, Individual Funding Co-ordinator, BCCG (drugsbeds.notify@nhs.net {Secure Fax – 01234 409431}, Gilbert Hitchcock House, 21 Kimbolton Road, Bedford MK40 2AW. G:\Prescribing Team\commissioning\Commissioning\Proformas\2013_14 Final proformas new logo\CSSI or Insulin Pump TA 151_Adults only FINALnew logo.doc

Patient NHS No

Rhian Stacey

2017-07-10

gem

SUTTON & MERTON PCT