Medifer Pre-Authorisation Form

Practice Details
Practice Name*
PCN Name*
Practice Code/ODS*
List size*
GP Clinical System*

EMISSystmOne
EMIS ID site code (if applicable)
Admin/IT Lead for system access*

NameNHS Email
Practice Manager/Referral Admin Lead

NameNHS Email
Clinical Lead*

NameNHS Email
Pre- Audit Checklist
Practice wishes to arrange a virtual meeting to discuss project*

YesNo
Practice agree to provide access to eRS*

Yes
Practice approves the service to be conducted remotely with the required data security assurance*

Yes
Clinical Lead would like to review patient list prior to MMS contacting patient*

YesNo
Practice agrees for MMS to contact patient via AccuRx and or teleconsultation to assess further eligibility and consent for referral to Medefer pathway.*

Yes
Clinical Lead would like to review referral list prior to MMS changing provider*

YesNo
Pharmacist to complete new referral for patients agreed to Mederfer pathway*

Yes
Please add any further comments in relation to the scope of service or MMS activity in relation to the Medefer Referral Service at your Practice:
Please note, details of Patients screened and reviewed/referred to Medifer as part of this service will be shared with the surgery.
Service authorised by*

First NameLast Name
On behalf of (Practice name)*
Signature

Clear
Please verify your submission*
*Remote working will only be conducted after sharing a Data Processing Agreement

Dec 2024
Should be Empty:

Practice Details