Name of Policy/Procedure or Guidance

Overseas Visitors Policy

Date issued:

Dec 05

Date to be returned:

Dec 08

Lead/comments to be returned to

Simon Marshall - Director of Finance

Andy Finlay - Income Generation Manager

Amendment No.

Date

Detail

Page No(s).

Paragraph No(s).

1

June/July 2006

Insertion of the three consultants rule for discharge when stable.

25

2

July 2006

Insertion of clause with regard to other government departments failing in their statutory duty.

37

3

Jan 2007

Romania & Bulgaria added to EU regulations

46

4

Jan 2008

Reviewed by LCFS, additional sentence to advise that it is a criminal offence to provide incorrect or misleading information on the form. Strengthen the wording to include LCFS & Police action

30, Appendix 1, Part C

5

Jan 2008

First paragraph, stage 2 interview, rewording for readability reasons.

31, Appendix 2,

6

Jan 2008

Finance Use only added to Overseas Patient Record form -financial information record

30, Appendix 1

7

April 2008

Rewording of Para 7.9 - Stabilise & Discharge Protocol.

25

8

April 2008

Addition of para 5.6 - 18 week wait

21

Name of Policy, Procedure or Guidance

Overseas Visitors Policy

Reference Number (to be inserted by Intranet Manager)

Who should read the objectives of this policy/procedure

All Medical Staff, Admin & Clerical Staff, Finance Staff, Nursing Staff, Associate Directors, Directors

Executive Summary

Correctly identify those patients who do not normally reside in the UK, who seek treatment at WMUH and issue charges to protect Trust Resources.

Committee & date approved

Ratified by Trust Board on:

(only insert date if appropriate)

Review Date

Dec 2008

Director(s) responsible for ensuring this document is implemented

Simon Marshall - Director of Finance

For further information contact

Andrew Finlay - Income Generation Manager

[phone numbers removed by WhatDoTheyKnow], [phone numbers removed by WhatDoTheyKnow]

The formal/legal documents forming the basis of this document are

Implementing the Overseas Visitors Hospital Charging Regulations- April 1989, amended 2004

Cross reference to

NHS Act 1977

Section

Description

Page

1

Introduction

3

2

Aims

4

3

The Law in England & Wales

5

4

The Regulations Explained

8

5

Procedure for Establishing Eligibility

15

6

Roles & Responsibilities of Trust Officers

19

7

Procedure for all Interviews

20

Appendices

1

Overseas Patient Record Form

27

2

Stage 2 Interview Record

28

3

Credit/Debit Card Declaration

29

4

Medical/Holiday Insurance Form

30

5

But what about….? A-Z of Overseas patients

31

6

Base Line Questions

41

7

Quote for Care

42

8

EEA and Non-EEA Bilateral Agreements

43

9

Out of Hours Form

44

10

Advice for Medical Practitioners

45

11

Standard letter to Patients

46

12

IGA Form

47

13

NHS IND Enquiry

48

A&E - Treatment given in an accident and emergency department, a walk-in centre, a minor injuries area, an A&E clinic or an Observation Ward attached to an A&E department. This exemption from charges ceases when the patient leaves the area and is admitted to a ward or given an outpatient appointment. To clarify a common misconception, emergency treatment is not exempt; the area in which the treatment is administered is exempt. The same emergency treatment given in ITU is chargeable or CCU is chargeable.

Community - Some services provided in the community will be chargeable only where the staff are employed by a Trust, e.g. District Nurses by a PCT. However a Practice Nurse employed by a GP providing a service is NOT chargeable.

Public Health Protection - There are certain diseases where treatment necessary to protect the wider public health. They are as follows:

Acute encephalitis

Plague

Acute poliomyelitis

Rabies

Amoebic Dysentery

Relapsing Fever

Anthrax

Rubella

Bacillary Dysentery

Salmonella infection

Cholera

SARS (Severe Acute Respiratory Syndrome

Diphtheria

Scarlet Fever

Food Poisoning

Smallpox

Leprosy

Staphylococcal infections

Malaria

Tetanus

Measles

Tuberculosis

Meningitis

Typhoid Fever

Meningococcal septicaemia

(without meningitis)

Typhus

Mumps

Viral haemorrhagic fevers

Opthalmia neonatorum

Viral hepatitis

Paratyphoid fever

Whooping Cough

Yellow Fever

Treatment given in, or as the result of a referral from an STD Clinic - This does not apply to treatment for HIV Positive patients who must pay for any treatment beyond an initial diagnostic test and any counselling associated with the test or its result. An overseas visitor with HIV/AIDS referred to a hospital from such a clinic will be liable for charges unless otherwise exempt.

For example, a Patient with TB & HIV, the treatment for TB will be exempt from charges, however the patient will still incur charges for the treatment of HIV.

Detained under Mental Health Act - All treatment given to people detained under the Mental Health Act or a probation court order is exempt.

Ordinarily Resident

A person lawfully living in the UK voluntarily and for settled purposes as part of the regular order their life for the time being. They should have an identifiable purpose for their residence here and that purpose should have sufficient degree of continuity to be properly described as `settled'.

Treatment provided in A&E, Minor Injuries units and Observation Wards attached to A&E departments is exempt. The exemption from charge ceases when the patient leaves the department, i.e. is admitted to a ward within the hospital or is referred to an outpatient clinic. The common misconception is that `emergency' treatment is free, it is not, it is the location that is exempt not the treatment. Trusts have an obligation to treat patients who have life threatening conditions and to provide immediately necessary treatment, irrespective of ability to pay.

Once status has been determined this MUST be entered into Camis:

This must be carried out for every patient

Once status has been determined this MUST be entered into Camis:

This must be carried out for every patient

Leeds North East Primary Care Trust

Overseas Visitors Section (Finance)

Sycamore Lodge

7a Woodhouse Cliff

Leeds

LS6 2HF

OVERSEAS PATIENT

Please contact:: Income Generation Manager

for Overseas Patients

[phone numbers removed by WhatDoTheyKnow], [phone numbers removed by WhatDoTheyKnow]

LIABLE

EEA

NOT LIABLE

Name of Patient

Hospital Number

Date of Birth

WARD/AREA

UK Address:

Home Address

Diagnosis/HRG:

Admission / Activity Date:

Discharge Date:

Name:

UK Address:

Home Address

Relationship to patient

Paid in Full

Paid in part:

Payment Method:

Insurance - Invoice

Balance payable:

Receipt Number /Authorisation Code

Requested by:

Designation:

Date of Receipt:

Referred by

Under the Care of

Bleep

Comments

Diagnosis

Affix patient label here:

LIABLE

NOT LIABLE

Patient Name

Patient Signature

Date

Overseas Patients Manager

Signature

Date

Patients name:

Hospital Number:

Ward/Area:

Consultant:

Name on Card

Card Issuer

Start Date

Expiry Date

Signature

Card Number

(Long number through the centre of the card)

Amount

£

Security Code

(Last three digits on the signature strip)

Signed on behalf of West Middlesex

Designation

Date

Patient:

Hospital Number:

Name of Company:

Address of Company:

Policy Number:

Contact Name at Company:

Level of cover

Patients Name:

Date:

Signature

Abortion

See Termination of Pregnancy (ToP)

AIDS

See HIV

Ambulance Services

The Regulations do not apply to ambulance services. These should be provided free of charge where they are part of the patients clinical need.

Artificial Limbs

See Prosthetic services

Asylum Seeker

A person who has made a formal application to the Home Office for recognition as a Refugee under the 1951 UN Convention and its 1967 Protocol Relating to the Status of Refugees.

Au Pairs

Au Pairs are not employed as such and therefore are not automatically eligible for free treatment. Au Pair is a technical term applied by the Home Office when granting entry to the UK, usually for a minimum of two years, and it can apply only to people from certain countries. Many of these countries have bilateral healthcare agreements with the UK or are EEA member states or Switzerland, so the au pair would be eligible for any treatment, which arises during the visit.

Alternatively the Au Pair coming to the UK can be settled and living for a period of time may be considered `ordinarily resident'.

The Trust must decide on each individual case and it be judged on its own merits.

Authorised Child

A child of a person who has been given leave to enter the UK with a parent who has come to the UK for specified treatment under provision of Regulation 6A; or a child of an authorised companion of such person given leave to enter the UK. There may be several authorised children travelling with the exempt person or their authorised companion. An authorised child is eligible for free treatment the need of which arises whilst they are here.

Authorised Companion

A person who has been given leave to enter the UK with a parent who has come to the UK for specified treatment under the provision of Regulation 6A. There will normally only be one authorised companion, and they will be eligible for free treatment which arises during their stay here.

BaseLine Questions (BLQ)

All Trusts should have systems in place to ask all patients beginning a new course of treatment at the Hospital the BaseLine Questions. (There is a page in every set of notes that asks these questions and a copy of the flowchart for distribution is contained in Appendix 6).

Where a person's answers to the BaseLine Questions indicate they may be chargeable, they must be referred for a second interview with a trained member of staff to establish eligibility. (Directorate Income Generation Manager or Other Stage Two Officer.)

Community Services

Some services delivered in the community will be subject to charge as services delivered by WMUH on behalf of the community. Where staff not supplied by WMUH supplies services then the charging regulations do not apply.

Confidentiality

WMUH staff becoming aware that a patient may be here without the proper authorisation must make a decision in the full light of the patient's circumstances as to the reporting of their immigration status. It is important each case is judged on its own merits. There is a public interest argument in the reporting of such patients but this should be weighed with the medical confidentiality rules and the medical needs of the patient. It must be discussed with WMUH Caldicott Guardian. (Janet Baldwin - Medical Director). With a possible view to discuss with WMUH legal advisors also.

Dependant children visiting an ordinarily resident parent

Where are child who normally lives abroad is visiting a parent who is ordinarily resident in the UK, that child can take on the status of the parent if they have dual access or joint custody.

Dependants

For all patients, except those from EEA member states, dependants are limited to marriage partner and children under the age of 16, or under 19 if still in fulltime education or receiving child benefit. For EEA member States the accepted dependants of a person will be named on the relevant E form issued or other identity documents.

Dialysis

The Regulations, and therefore the charges, apply where visitors to the UK require haemodialysis or peritoneal dialysis for the treatment of kidney failure.

Domiciliary Nursing

See Community Services

Dual Residence

A person with homes in more than one country may be considered ordinarily resident in the UK if the are likely to spend at least 9 months of the year living in the UK. However, if they are a person in receipt of a British State Pension who spends not more than 6 months living in another EEA member state and not less than six months living in the UK then they will be exempt under Regulation 4A even though they spend more than 3 months in another EEA member state.

Employment

The Regulations do not define employment other than to make clear self-employment is included, and that it must be with an employer based in the UK or at a registered UK branch of an overseas employer.

Self-employed workers must show that their principle place of business is the UK.

Generally where there is any doubt that a person is employed it can be satisfied by asking to see (up to date) documentary evidence from the employer, or in the case of a self-employed person, a letter from a reputable bank or solicitor.

Part time work will also count but WMUH must satisfy the reason for being in the UK is primarily to work. Where are a person has entered the UK as a visitor and has applied to switch to employed status then this will not count.

Establishing Responsible Commissioner

Full Guidance can be found at

http://www.dh.gov.uk/assetRoot/04/06/97/97/04069797.pdf

General Practitioners

The Hospital Charging Regulations do not apply to General Practice. GP's are able to offer treatment to overseas visitors on a private basis but can also accept them as NHS patients, i.e. exempt this is in accordance with the Human Rights Act 1998. Such patients may receive an NHS card and number. This does NOT automatically entitle them to treatment without charge at WMUH, nor does the fact that they may be have been referred to WMUH by a GP.

WMUH remains responsible for checking that all patients - including those with NHS cards or numbers - are ordinarily resident in the UK or otherwise exempt before treating them without charge, unless care is required before liability status can be established, e.g. major medical emergency..

Health Visitors

See Community Services

HIV

There is no charge for a diagnostic test and any associated counselling to establish if a patient is HIV positive. Any further treatment needed, including the full cost of drugs, for HIV or AIDS is liable to charges. If a liable patient is in possession of a HC2 certificate this does not exempt them from charges for drugs for HIV/AIDS treatment.

Hospital at Home

See Community Services

Illegal Immigrants

It may happen that during investigations to establish a patient's residence it transpires that the person is in the UK without proper permission. This may be that they entered the country on a visitor's visa that has since expired or they may have an application for asylum rejected but have not yet been removed from the country. In these cases charges may apply depending on the circumstances, particularly if they have been in the UK for more than 12 months. (See confidentiality)

If the Trust can prove that another government department has failed in their statutory duty to remove persons from this country WMUH will not accept the financial responsibility for these person(s) and will move to transfer the outstanding balance to the relevant department that has failed WMUH.

Immediately Necessary Treatment

WMUH needs to treat patients in need of immediately necessary care regardless of their ability to pay. This may be because their condition is life threatening, or because if treatment is not given immediately it will become life threatening, or because permanent serious damage will be caused by any delay.

It is a matter of clinical judgement that should not be second-guessed by administrative staff.

However, in the interest of good audit management, the responsible health professional's reasons should be recorded in the patient's clinical notes and the request for advice from a doctor (Appendix 10) should be completed.

Where immediately necessary treatment occurs and WMUH knows that payment is unlikely, treatment should be limited to that which is clinically necessary to enable the patient to return to his or her own country.

This should not normally include routine treatment unless it is necessary to prevent a life-threatening situation. Any charge payable for such treatment will still stand, but if it proves to be irrecoverable, then it should be written off.

Israel

There is no general bilateral healthcare agreement with Israel but a person entitled to industrial injuries benefit in Israel is fully exempt from NHS charges for treatment arising from their industrial injury or occupational illness.

Maternity Services

Maternity services are not exempt from charges. However because of the severe health risks associated with such conditions such as eclampsia and pre-eclampsia, maternity services should not be withheld if the woman is unable to pay in advance. The patient remains liable for charges and the debt should be pursued in the normal way.

Women from EEA countries and Switzerland are covered for all maternity care i.e. antenatal and postnatal care for up to 15 weeks after the birth of the child.

Women from non-EEA countries with which we have bilateral healthcare agreements are eligible to receive immediately necessary treatment in connection with their pregnancy, if an unexpected emergency arises during their visit. This applies irrespective of whether the pregnancy was confirmed in the UK or elsewhere.

However if they come to the UK or remain in the UK to obtain routine antenatal care or deliver their baby then charges will apply, unless they are specifically referred to the UK under agreement because of complications.

Midwifery

See Community Services

Newborns

Where a baby is born in hospital mother and child are charged as a single patient. If one of them is transferred to another department, e.g. SCBU, the charge will continue to accumulate to recover the full costs of treating them both.

If one is discharged and the other remains the charge will continue to accumulate to recover the cost of treating the one remaining. If either is transferred to a different hospital then that hospital will be responsible for recovering the costs for the treatment that they provide.

NHS Card or Number

Having an NHS card or number does not give automatic entitlement to free NHS hospital treatment. Every patient's eligibility should be checked.

NHS Charged Patients

Overseas Visitors who are liable for charges are NHS charged patients. They should not be confused with private patients. They must receive the same priority as NHS patients.

Unlike private patients NHS charged patients are liable to pay for their treatment even where an undertaking to pay has not been obtained.

No Recourse to Public Funds

A stamp on some visitor's passports. It does not apply to NHS treatment but prevents people from accessing UK social security funds.

Non-urgent treatment

Routine elective treatment that could in fact wait until the patient returned home.

The patient's chargeable status should be established as soon as possible after the 1^st referral to WMUH. Where the patient is chargeable WMUH will not initiate treatment processes, including assigning a waiting list entry, until a deposit equivalent to the estimated full cost of treatment (Quote for care Appendix 7).

Any surplus, which is paid, can be returned to the patient on completion of treatment. This is not refusing to provide treatment, it is requiring payment conditions to be met in accordance with the charging regulations before treatment can commence.

Norwegian Seafarers

A Norwegian national employed on a Norwegian registered vessel is exempt if brought to the UK for treatment on or from that vessel.

Observation Wards

Patients kept in the Observation Wards attached to A&E at WMUH should not be charged unless they are formally admitted to the hospital as an inpatient.

Offshore Workers

A person working in UK territorial waters or in the UK sector of the Continental Shelf is exempt, as is an offshore worker working elsewhere on the shelf if his employer or contractor has his principal place of business in the UK.

One Year Rule

There is no `one year rule' that's says you have to be in the UK to receive free treatment at WMUH. This should not be confused with the exemption for people who have been living lawfully in the UK for 12 months immediately preceding the date at which treatment Is given. Someone who is ordinarily resident, or is exempt under one of the other exemptions is entitles to free treatment from the day they arrive in the UK, there is no qualifying residence period.

In order to take the House of Lords judgement into account, when assessing the residence status of a person seeking free NHS services, WMUH must consider:

“….living lawfully in the UK voluntarily and for settled purposes as part of the regular order of their life for the time being whether they have an identifiable purpose for their residence here and whether that purpose has sufficient degree of continuity to be properly described as `settled'.”

Overseas Visitor

Any person of any nationality who is not ordinarily resident in the UK.

Permanent Residence

People taking up permanent residence in the UK are entitled to free hospital treatment. They must however have the legal right to live here permanently and WMUH can ask to see evidence of that right before exemption can be granted.

People who have a right to live here and claim to be returning here permanently to the UK after living abroad can be asked to provide evidence to support such a move - perhaps the sale of such property abroad, shipping of belongings, transfer of assets, etc

People who have made applications for permanent residence will be chargeable up until they are granted leave to remain by the Home Office or they have completed 12 months lawful residence and then charges will cease.

Where are person applies to extend their current entry visa, only those claims that are made before the existing visa runs out will be considered as lawful residence.

Where a person applies to extend their leave to remain after their current visa has expired the calculation of 12 months lawful residence starts from the date they reapplied.

Prisoner

Anyone who has to be detained under provision of section 43(1) of the Prison Act 1952 or anyone who has been detained under provision of the Immigration Act 1971.

Prosthetic Services

The artificial Limb and Appliance services are not provided under the NHS Act 1977, and the overseas visitors charges Regulations made under that Act cannot therefore apply to services provided by them.

Patients who are liable for charges under the Regulations and who needs artificial limbs or appliance must therefore obtain them privately.

Public purse

A term used in some travel documents to signify the holder cannot access UK social security benefits. It does not apply to NHS treatment.

Refugee

A person who has been granted asylum by the UK government has been recognised as a refugee (a successful asylum seeker) and is exempt from charges.

Repatriation back to the UK

When a person goes to live outside of the UK the NHS ceases to have responsibility for their healthcare. If such a person is taken seriously ill the NHS is not responsible for funding their repatriation back to the UK.

However if a patient's family make their own arrangements to repatriate the patient who on arrival will be resuming their permanent residence, then they will become entitled to access full NHS treatment from the date of their arrival.

If WMUH is advised in advance of the patient's arrival the we must make adequate arrangements to ensure that the patient receives the appropriate healthcare upon their arrival back in the UK.

Repatriation back to the Visitors home country

Where a person has received NHS treatment and has not been able to pay for that treatment and expresses a wish to return home, WMUH can consider funding the cost of the repatriation if the cost of the repatriation outweighs the cost of treating the patient and will therefore produce a cost saving for the Trust and if the patient gives consent to return home.

It is not possible to force repatriation of a patient.

Routine Monitoring

This includes routine monitoring of conditions like diabetes. Such provision will not be covered under existing non-EEA bilateral healthcare agreements and charges will apply.

Seamen or women

A person working on a UK registered ship is exempt from charges. A person who is working on any other registered vessel is exempt if they are ordinarily resident in the UK.

If they are from an EEA country or Switzerland, a non-EEA bilateral healthcare country and the need for treatment arose in the UK or on a voyage to the UK; or if they are a former UK resident and the five or ten year exemptions apply.

Six month Rule

There is no six-month rule that says you have to have been in the UK for six months before you are entitled to free NHS treatment.

Sponsors

Some people are allowed into the UK only because another person or authority has agreed to sponsor their stay here and guaranteed that they will not become a drain on the public purse. The public purse does not include NHS treatment, therefore sponsored people can use the NHS and must be exempt in their own right.

A sponsor is not liable for NHS charges and charges must be sought in the same way as an overseas visitor if the person requires NHS treatment. Even if the sponsor has offered to pay.

Spouse (and children)

Where a person is exempt from charges for NHS hospital treatment then so is their marriage partner (but not an unmarried co-habitee or `common-law' partner) and children when they are either:

The exempt person must be in the UK with their spouse and/or children.

Where a person is ordinarily resident and their spouse lives abroad, the spouse will not be considered ordinarily resident on a visit to the UK. Unless they meet one of the exemptions from charge in their own right then they are liable for charges.

State Pensions

The following are UK state pensions to which there is entitlement under the Social Security Act 1975 and which could apply to a person living overseas:

Occupational pensions (including civil service pensions) are not state pensions.

Students

People who are pursuing a full time course of study of not less than 6 months in duration or people who are pursuing a full time course of study of any duration which is funded either wholly or substantially by the UK government. A person here on a visitor's visa spending a few hours a week learning English is a visitor not a student and therefore liable for charges.

Termination of Pregnancy (ToP)

Where a patient seeks a ToP and is liable for charges but is unable to pay in advance the hospital may decline to provide the service and should advise the woman to seek termination in her own country.

The only exception to this is where the woman's life is at risk. In these circumstances the termination should take place. The patient remains liable for charges and debt should be pursued in the normal way.

Women from a bilateral agreement country who come to the UK specifically to seek ToPs will be liable for charges unless they have either, (for EEA nationals, obtained an authorised E112 form from their own health institutions,) or for Non-EEA bilateral agreement countries, have been specifically referred for treatment under the terms of the agreement.

Treatment the need for which arose during the visit

The limiting of access to treatment without charge to conditions, which occur, only whilst present in the UK or in the Doctors opinion, although pre-existing, need immediate treatment to prevent deterioration.

Twelve Month Rule

See one year rule

UK Government Financed Posts

People claiming exemption under this Regulation should be able to provide satisfactory documentary evidence of their entitlement. Recruitment must have taken place in the UK and will include people working for the Department for International Development and the British Volunteer Programme.

UK Government Financed students

People who are pursuing a full time course of study, of any duration, which is funded either wholly or substantially by the UK Government. The must provide satisfactory evidence of their entitlement.

Unaccompanied Minors

Children of overseas visitors will rarely be exempt in their own right, but only via their parent's status. Thus where treatment is given to a child under the age of 16 who is in the UK without his or her parents it will be chargeable unless the treatment itself is exempt (e.g. provided solely in the A&E department or the Observation Suite. The liability should be explained to the person in whose charge the child has been left (e.g. teacher, tour leader, host) and the bill handed to that person. Copies should be sent to the child's parents.

A further exception is that children from EEA member states or Switzerland who will be eligible for free treatment the need for which arose during their visit (E111 or EHIC arrangements) as will children from bilateral agreement countries.

A further exception is unaccompanied minors attending boarding school in the UK whose parents both live outside the UK. In this case the child will be classed ordinarily resident while at school because in legal terms the school act in loco parentis.

Unemployed persons

There is no exemption for unemployed persons with the exception of people here under specific EEA arrangements. This person will have a copy of form E119, without this form they are liable for charge.

Urgent treatment

Where the treatment is, in a clinical opinion, not immediately necessary, cannot wait until the patient returns home. Patients should be booked in for treatment, but the Trust should use the intervening period to establish the patients' chargeable status.

Wherever possible, if the patient is chargeable, WMUH should seek a deposit for an estimate of the full cost of care. Any surplus could be returned to the patient upon completion of treatment.

Volunteers coming to the UK

Exemption from charges is limited to those people who are providing services that are similar to health or social services.

Volunteers from the UK

People who leave the UK to spend time as a volunteer are not automatically entitled to return to the UK for free hospital treatment. Each case should be carefully considered. Only people working on a UK government financed project are automatically entitled. Others may be if they are returning to take up permanent residence and they can be exempted under ordinarily residence criteria.

Waiving charges

No power has been given, in the Regulations or otherwise, for any person, including the Trust Chief Executive, the lead Consultant or a Government minister, to waive charge which are due.

War pensions

The holder of a UK war disablement pension is fully exempt from charges not just those relating to his or her injury. His or her spouse and children are also fully exempt. The holder of a UK war widow's pension is also exempt.

Write-off debt

Where debt is unrecoverable WMUH can write it off. However, the Trust must take all reasonable measures to recover the debt, including consideration of using a debt collection agency if it's financially viable.

Overseas debt must be written off correctly.

Patient Name

Date of Birth

Postcode

Home Address:

Ward/Area:

Admission Date:

Discharge Date:

INPATIENT STAY

TO

COST:

£

TRANSFERRED TO:

INPATIENT STAY

COST:

£

DRUGS

£

MINIMUM REQUIRED

£

Signed (patient)

Date:

Signed (on behalf of WMUH)

Date:

Anguilla

Kazakhstan *

Armenia *

Kirgizstan *

Australia

Macedonia *

Azerbaijan *

Malta *

Barbados

Moldova *

Belarus *

Montserrat

Bosnia *

New Zealand *

British Virgin Islands

Poland

Bulgaria

Romania

Channel Islands

Russia *

Croatia *

Slovak Republic *

Czech Republic *

Slovenia *

Falkland Islands

St Helena

Georgia *

Tajikistan *

Gibraltar *

Turkmenistan *

Hungary *

Turks and Caicos Islands

Iceland

Ukraine *

Isle of Man

Uzbekistan *

Yugoslavia, * i.e. Serbia & Montenegro

Form Completed by

Job Title

Bleep Number

Signed

Patient Name

Date of Birth

Postcode

Home Address:

UK Address:

Ward/Area:

Admission Date:

Credit Card details recorded YES/NO

Reason for NO:

Dear Doctor

NAME OF PATIENT

Date of Birth:

Hospital Number:

Date: Signed: (Doctor)

Print Name:

Date: Signed: (Overseas Visitors Manager)

Print Name:

^{IGA (Previously IGA 19) DEPARTMENT OF HEALTH}

^{Financial Monitoring of Overseas Visitors Episodes of Care for Recovery of UK Costs}

^{ALL SECTIONS OF THIS FORM MUST BE FULLY COMPLETED}

^{NHS TRUST} ……………………………………………………………………………………………………… ^{PGO No} …………………….

^{LEAD COMMISSIONER ………………………………………………………………}……………………………………………….^…………. ^{ORGANISATION CODE} …^{……………}…

^{Total cost:} …..………………………

^{PATIENT DETAILS}

^{Local Patient Identifier:} ………...

^{Patient's Name (Surname/Forenames):} ………

^{Date of Birth: DD/MM/YYYY} .^....…..^/....…...^/....……

^{Patient's Usual Address:} ………...

………...

^{Date of arrival in UK DD/MM/YYYY ……}…^/……….^/…^………

^{Postcode of Usual Address (use NHS User Postcode Directory - 5th & 6th ……}.. ^……..

^{(characters only. NOTE the codes may}

^{Patient's Nationality (not be the same in both sections) ……}.. ^……..

^{INPATIENTS and DAYCASES:}

^{Start Date: DD/MM/YYYY ……}…^/………^/………

^{End Date: DD/MM/YYYY ……}…^/………^/………

^{Diagnosis: Primary (ICD 10 Code): ……… Operative Procedure: Primary}

^{Operation (OPCS4 Code): ………}

^{Specialty Code: ………}

^{Health Care Resource Group Code ……………….}

^OUTPATIENTS:

^{Attendance Date: DD/MM/YYYY ....…}..^/....…..^/....……

^{Source of Referral: ……… Reason for Referral: ………}

^{Outcome: ……… Specialty Code: ………}

^{OTHER CONTRACT DETAILS}

^{Was the patient referred by an overseas authority? YES/NO}

^{If YES and the patient is from EEA: a copy of the E112 must be attached}

^{State Quota number if appropriate: …………}

^{Patient's Guide category under which treatment was given …………….}

C^{ONTACT FOR ENQUIRIES} ………………………………………………………

^{(staff member who completed the form)}

^{TELEPHONE NUMBER/EXT} ……………………..

^{PLEASE SEND THIS FORM TO: Overseas Visitor Section} (Finance Dept)^, Leeds North East PCT, Sycamore Lodge,

7a Woodhouse Cliff, Leeds LS6 2HF. Tel 0113 3059790 or 3059795 Fax 0113 3059870

Patient name:

Date of Birth:

Country of Origin:

Date of Arrival in Country:

Purpose for being in UK:

Home Office Reference or ARC Number (if applicable)

The patient authorises this request:

Signature of patient:

FROM:

Name of Hospital:

Name & Job title:

Please advise what this person's immigration status is

OR

Please advise whether this person's ARC is still valid

If no longer valid has asylum claim been

granted ………………………………. OR refused ………………………………………

Please state reason for non-removal from the UK

………………………………………………………………………………………………..

Patients name

Ward/Area

Name

Signature

Amount

£

INPATIENT STAY AT WMUH/

Address

Signed on behalf of West Middlesex

Designation

Income Generation Manager

Date

Copy to be made and handed to patient

Original to be retained in Finance

Consultant 1: (Medical Director)

Consultant 2:

Consultant 3:

Income Generation Manager:

Patients Hospital Number:

Patients Name:

Charges Outstanding:

Reason for request:

Area of Activity:

Admission Date:

Discharge Date:

X1 copy to be filed in the patients notes

X1 copy to be held in Finance