CONSENT FORM SPONSORED MEDICAL TREATMENT ABROAD

Transcription

1 Appendix 5.4A Treatment Abroad Section Administration Block Mater Dei Hospital Msida MSD 2090 Tel: (+356) /1/2 Fax : (+356) specializedreferrals.msoc@gov.mt NATIONAL HIGHLY SPECIALIZED OVERSEAS REFERRAL PROGRAMME CONSENT FORM I hereby give consent for such surgical and medical treatment and investigations which may be found necessary to be carried out on (ME) the nature of which has as far as possible been explained to me by my doctor and give my consent for anaesthetics to be administered. I agree to leave the nature and extent of any operation or operations to the discretion of the surgeon. Patient. Husband.. Address : Witness to signature/s or Marks. Date. MIS/1004/01.0 Data Protection Statement All personal data is required to provide you with health care services as necessary. It is processed in accordance with the Data Protection Act, and as permitted by law. Further information about your data can be obtained on request.

2 Patient s Name : Date of Birth : Address : Phone No.: Mobile No.... Married/Single/Widow/Widower Occupation (if retired state previous occupation) Next of Kin: Name Address.. Relationship to patient.. Director General Department of Health I am informed that approved sponsorship. has recommended me for treatment abroad, and that Government has I hereby undertake to abide by the conditions of sponsorship stipulated hereunder. Conditions of sponsorship: 1. In these conditions of sponsorship the term Protected Person shall mean a patient falling under the authority of the legal guardian(s) signing these conditions.

3 2. I acknowledge and understand that the sponsored care and treatment which will be provided to me or (if applicable) the Protected Person abroad shall be care and treatment which falls within the parameters of the National Healthcare Package of Care and that the Department of Health shall only bear the cost of care and treatment which falls within the NHS (National Health Service). Any treatment/investigations received in a private hospital will be my responsibility even if I am so referred from the UK NHS hospital. In such a case, the matter should be reported immediately to the Malta High Commission in London for appropriate action from their end. 3. I acknowledge that by accepting the said sponsorship facilities I:- a. Give consent for such surgical and medical treatment and investigations as may be found necessary to be carried out on me or (if applicable) the Protected Person; b. Give consent for an anaesthetic or anaesthetics to be administered to me or (if applicable) the Protected Person and undertake: i. To abide by all the rules and regulations of the hospitals and the institutions in the receiving country where I or (if applicable) the Protected Person undergoes treatment and investigations. When I am or (if applicable) the Protected Person is not in any such hospital or institution and the necessary treatment and investigations are not yet completed, I shall abide by any instructions which are given to me by the representative of the Department of Health in the receiving country; ii. To report to the Treatment Abroad Section and to my Consultant on my return to Malta and to abide by any instructions given by the Medical Officers of the hospital concerning the continuation of the treatment of Malta. 4. I hereby declare that I shall follow all such relevant policies and guidelines that have been explained to me by the Department of Health, and declare that I have understood all such policies and guidelines. I acknowledge that, in the event that I am eligible for reimbursement of any costs relevant to my treatment, such costs shall only be reimbursed (within the parameters, and up to the amount set forth by the guidelines) upon presentation of receipts.

4 5. I acknowledge and understand that the Department of Health is not responsible for the care provided to me or (if applicable) the Protected Person outside its jurisdiction and understand that the Department of Health is not liable for care and treatment provided to me or (if applicable) the Protected Person at any hospital outside the Department of Health s jurisdiction. 6. I understand that if I or (if applicable) the Protected Person, whilst still undergoing treatment, need not stay in hospital, alternative accommodation will be provided by the representative of the Department of Health in the receiving country. The relative expenses will be paid by the Department of Health but if I make my own arrangements for such accommodation this will be at my expense and responsibility and the Department of Health does not bind itself to refund any of those expenses. 7. My or (if applicable) the Protected Person s airfare to and from the receiving country will be paid by the Department of Health if, covered by the sponsorship policy in force at the time. In addition the head of the patient s household may submit to a means test under oath at one of the Offices of the Department of Social Security should sponsorship outside the policy be sought. When the head of the patient s household agrees to pay the passage the said means test shall not be required. For the purpose of this condition the definition of head of household shall be the same as that given in Social Security Act (Cap 318 of the Laws of Malta) as may be amended from time to time. 8. The choice of the country where I or (if applicable) the Protected Person is to receive the required treatment and investigations and the hospitals and Consultants in such country, shall be at the discretion of the Ministry (Health, the Elderly and Community Care). 9. Any dispute which may arise on any matter concerning sponsorship facilities which is not covered by these conditions shall be decided by the Ministry (Health, the Elderly and Community Care) whose decision shall be final and binding. 10. Failure to observe any of these conditions may entail the discontinuance of sponsorship facilities and the Department of Health shall have the right to claim refund, in full or part, of the expenses incurred by the Department on my behalf or on behalf of the Protected Person.

5 11. I hereby grant the Ministry permission to disclose sensitive personal data relating to me or (if applicable) the Protected Person to third parties located both in Malta and in the United Kingdom as and may be required in order for accommodation, transport and care abroad to be appropriately organized. 12. The representative of the Department of Health in London is: THE HIGH COMMISSIONER MALTA HIGH COMMISSION 36/38 PICCADILLY LONDON W1V 0PQ ( or ) Patient Father Mother.. Witness to marks or signatures Date:

6 Treatment Approval Policy Patient must be receiving treatment in Government Health Care entity in Malta and must be under the care of a Local Consultant. Patient must have received all possible treatment and has undergone all possible investigations locally. When all local options have been exhausted, his local caring consultant will recommend to the Treatment Abroad Committee that the patient be referred for further investigations and/or treatment in a UK NHS hospital by his local caring consultant. Patient s caring consultant will fill in a referral form for consideration by the Treatment Abroad Committee. A medical summary shall be drawn up and attached to the referral form. The referral form should be endorsed by the Clinical Chairperson of the referring specialty. Referral form and medical summary will be reviewed by the Treatment Abroad Committee who will take the ultimate decision whether patient is approved for treatment in the UK Medical records and scans are sent to UK for evaluation and advice by UK Consultants. Criteria used by Treatment Abroad Committee to evaluate referrals Each referral form is evaluated on the following grounds: Service can not be provided locally. The case been discussed with other local Consultants in other areas and thus was ascertained that patient has received all possible treatment locally. The service being requested forms part of Malta s Health Care package. The services being requested is clinically proven and is not in its trial phase. Further clinical information may be requested from local caring Consultants in order to have a clearer picture of medical aspects of the case under review. Transport Policy Patients receiving treatment in UK as government sponsored patients are eligible for transport services. Transport is booked by the Malta High Commission in London. Transport for patients is booked on the following parameters: Transport is provided from and to all Airports in UK. Transport is provided to attend hospital appointments. Transport is provided for patients only however a maximum of 2 accompanying persons can travel in the same car with patient, at the Health Departments Cost if space permits. If the patient opts to book lodging which is not in the proximity of the hospital the health department will not cover the cost of transport. Patients are given the possibility to book their own transport services and submit a claim for reimbursement of expenses against presentation of original receipts. Reimbursement will only be effected if the accommodation is within the paroximity of the hospital.

7 Refund Policy The Health Department is responsible to cover all treatment cost for patients who have been approved to receive treatment in an NHS Hospital in UK as a government sponsored patients. The patients may also be eligible for coverage of other benefits, which include airfares, accommodation and transport services. The Treatment Abroad Section takes responsibility to make the necessary bookings for airfares, accommodation and transport; however patients may opt to carry out their own arrangements. In such a case patients are eligible for refund of expenses. The refund will be made in line with what would have been the expense had the arrangements been carried out by the Treatment Abroad Section. Expenses will only be refunded on presentation of original receipts. If patients opt not to eat the meals provided by the Franciscan Sisters they will be eligible for refund for food consumed in other places. The refund will not exceed the amount that would have been paid to the sisters had the patient consumed the meals provided by the Franciscan Sisters. In cases were patients are residing outside London such as Oxford, Manchester, Liverpool and Sheffield the maximum refund to patients will be of 20 a day to cover breakfast, lunch and dinner. Refund will only cover meals consumed by the patient. Patients may also be eligible for refund of expenses incurred for medical treatment or medical supplies, during their stay in UK. These expenses will only be reimbursed if the items procured are directly related to the treatment being received. No refund shall be entertained for medical services received in private hospitals/clinics or for services for which no prior authorisation was sought. Accommodation Policy The MHEC has agreements with the Franciscan Sisters in London and Puttinu Cares Foundation who offer accommodation services to patients receiving treatment. Payment to these institutions is made by the MHEC. The Sisters accommodation is based in Victoria, London and is easily accessible to hospitals based in London. The apartments owned by Puttinu Cares Foundation are based in Surrey and these are generally used by patients receiving treatment at the Royal Marsden Hospital in Sutton, Surrey. In cases where patients are receiving treatment outside London (such as Oxford, Manchester, Sheffield), accommodation arrangements are carried out by the Malta High Commission. The patient would be expected to pay for accommodation and meals and is then reimbursed on his/her return to Malta.

8 Accommodation arrangements are as far as possible made in lodging close to the hospitals where the patients are receiving treatment. The patients are free to make their own accommodation arrangements and are eligible for capped refund on presentation of original receipts. The refund is equivalent to what would have been paid had the patient stayed in the accommodation provided either by the Sisters or by Puttinu, depending which would be the closest. If accommodation is available in the vicinity of the hospital but patients opt to stay in lodging which is far, the department is not bound to provide transport between lodging and hospitals. Airfares Policy Flight arrangements are generally carried out by Treatment Abroad Section and arrangements are made with Air Malta, however patient may opt to make their own flight arrangements and ask for refund if they qualify for free tickets. The refund will not exceed the amount which would have been paid had arrangements been made by the staff at the Treatment Abroad Section. Patients are generally issued open tickets as the return date from the UK is unknown. If patients are paying for their ticket they will be advised to purchase open tickets, however if patients opt to purchase return tickets, the department will not take responsibility for any charges incurred by the patient or his/her relatives if tickets have to be changed in case of changes in appointments effected by the hospitals. Patients over the age of 18 years do not automatically qualify for free air tickets and thus have to submit to a means test. Patients will only become eligible for free air tickets if during the treatment period he/she opts to undergo another means test and presents documentation stating that he/she has satisfied the means test. If a patient does not satisfy the means test and thus has to pay for the air tickets but has to travel as a stretcher case, the additional costs for the stretcher are borne by the MHEC. If a patient needs to travel accompanied by a nurse or doctor, the escort expenses of the medical team are all covered by the MHEC. In the rare circumstances when patients would have to travel on an air ambulance, the air ambulance fees are also covered by the MHEC. As of 2010 patients under the age of 18years will automatically qualify for free air tickets. Additionally the air ticket of one accompanying person will also be covered when travelling with patients under the age of 18 years. Period between appointments If patients are fit to travel they are expected to return to Malta between appointments if the period between appointments is of 10 days or more. On the other hand, patients will be required to stay in UK if the period between appointments is of 9 days or less. If patients opt to stay in UK between appointments when period of wait exceeds the 10 days, patients will be expected to cover the cost of accommodation.

9 If patients indicate that they must stay in UK in view that they are not fit to fly as per instructions from the Hospital Medical Team, patients are expected to present written documentation from the hospital indicating that patient cannot travel with a clear explanation why restrictions to fly are being imposed. Patient. Father. Mother Witness to marks or signatures.. Date