ECO4 NHS REFERRAL

ECO4 NHS REFERRAL
Patients Name*

First NameLast Name
Patients Address & Postcode*
GP Surgery Name, Address and Postcode *
Please fill in the relevant Council
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 disease,Limited mobility,Immunosuppression,
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.
General Practitioner (Doctor Name inc. title)*
Email*
example@example.com
Phone number*
GMC Number
Signature*

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Date

DayMonthYear
Date
ECO Improvements Experts Ltd, 84a Hinckley rd Leicester Le3 0rd, Company number: 13607552
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