NHS Referral Application & Consent Form

ECO4 NHS Referral Application & Consent Form

Only complete this form if you've been asked to do this
Password*

Who is completing this application form?*
Important consent is needed from your customer and they must be present when completing this form. Consent surrounding the sharing of medical records is very strict and must be adhered to at all times. You cannot allow anybody but the patient to complete this application form.

Please note that the GP will call to check the necessary consent has been gained.
ECO Advisor / Surveyor Name
Please write your name if you are completing this with your customer
Patient Details
Patients Full Name*
Date of Birth*

DayMonthYear
Date
Address Line 1*
Address Line 2
Town/City*
Postcode*
Address
Local Authority*
Contact Number*
Email
An email with a copy of the completed form will be sent upon clicking submit PASSWORD TO VIEW PDF: intueco23
Surgery Details
Surgery Name*
Surgery Address*
Health Condition Category*
You can select more than one
Please choose the relevant Cardiovascular condition
Please choose the relevant Respiratory condition
Please choose the relevant Immunosuppresed condition
Please describe how you experience limited mobility
Other condition (not listed)
Please list your medical conditions and medication you are on*
Evidence Required
To be considered for an NHS referral, you need to provide one of the below forms of evidence (which clearly shows your name, address and date of birth):
- Screenshots from NHS App showing repeat prescriptions and extracts from 'health history' showing the relevant health condition
- Prescription slip (showing repeat prescriptions)
- Patient summary print out from surgery
- Letter from the NHS confirming diagnosis or appointment
- Benefit award letters:
  - Attendance Allowance
  - Disability Living Allowance - clearly showing the 'mobility component'
  - Personal Independence Payment - clearly showing the 'mobility part'
Please ONLY submit evidence for the patient named on the application.
Statement of Consent:
- I hereby give my permission for intuECO Ltd to collect and share information from my health records with a General Practitioner for the purposes of assessing whether I qualify for ECO funding under the NHS Referral route.
- I understand that personal information is held about me and I have shared parts of my health record to assist a GP to determine that I qualify for an NHS Referral.
- I have had the opportunity to discuss the implications of sharing or not sharing information about me.
- I agree that personal information about me may be shared and gathered from the following agencies:
  - NHS and other Health Services, including my GP practice
  - Relevant Local Authority for processing of the NHS Referral
  - OFGEM and other Government bodies for audit purposes for the ECO scheme
Your consent to share personal information is entirely voluntary and you may withdraw your consent at any time prior to ECO works commencing. Upon ECO works commencing, we have an obligation to keep your information securely stored for audit purposes for a period of 3 years after the scheme ends (until April 2029). For more information on our privacy policy please visit www.intueco.co.uk/privacy. Should you have any questions about this process, or wish to withdraw your consent please contact: hello@intueco.co.uk
I agree to my information being gathered and shared as described above.I agree for a GP to call me to discuss the information on this form if required.I declare that the information provided is true and accurate, and I consider myself vulnerable to the effects of living in a cold home.
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Patient / Customer Name*
Patient / Customer Signature*

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Date*

DayMonthYear
Date
HC Confirmed

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Intueco Ltd. Company Registration No 13172674 Registered office Charlotte House, Stanier Way, Derby DE21 GBF
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ECO4 NHS Referral Application & Consent Form

Evidence Required