(GP) NHS Referral

NHS Referral

Internal Use

Patients Name*

Patients Phone Number*

Address Line 1*

Town/City

Postcode*

Patients Address & Postcode

GP Address Line 1

GP Address Line 2

GP Postcode

Patients GP Surgery

Patients Surgery Address and Postcode

Please choose the relevant Council

https://www.gov.uk/pay-council-tax

Having carefully considered the patient's medical health conditions, I hereby refer the said patient for the ECO4 Flexibility (ECO4 Flex) policy, as set out by the Department of Business, Energy and Industrial Strategy (BEIS) via route 3: Person suffering from severe or long-term ill-health, as outlined in the ECO4 Flex Administrative Guidance, Route 3 refers to ECO4 legislated conditions listed below:

A cardiovascular conditionA respiratory diseaseLimited mobilityImmunosuppression

HC Category

READ ONLY - Pulled through from table - no manual selection available

C

R

LM

I

Person suffering from severe or long-term ill-health: I can confirm that the named patient suffers from one of the four health conditions listed above under Route 3 and that their health condition is adversely affected by living in a cold home.

*All referrals must be sent from a valid NHS email address.

Doctor Name (inc. title)*

GMC Number

Phone*

Email*

Must be a valid NHS email address

Signature*

Date

PASSWORD

Dropbox Folder

LA Text