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Haemorrhoidectomy Submission of this form is a declaration by the clinician that this patient meets the clinical criteria set out in the Nottinghamshire 2018 Restricted Policy for the procedure indicated. ONCE THIS FORM IS FULLY COMPLETED AND EVIDENCE OF CRITERIA BEING MET IS RECORDED IN PATIENT NOTES EMAIL THIS FORM TO: MACCG.IFRteam- [email protected] Greater Notts and Mid Notts CCGs may withhold payment to Providers for procedures that do not have prior approval declarations. Retrospective audits of Declarations are performed to ensure compliance with the Policy. This form can also be used to indicate that a procedure meets the exclusion criteria of the policy. Patient Details Name: Date of Birth: NHS No. GP Practice Clinician Details Name: Professiona l Reference Number: (GMC/NMC) Date: Organisation NUH SFHFT MSK HH PLEASE INDICATE THE RESTRICTED PROCEDURE CRITERIA DECLARED AS MET AND RECORDED IN PATIENT NOTES Before referral is made the referrer must confirm that the patient wishes to have surgery if offered NICE guidance is that haemorrhoids should be treated by band ligation. In the case of failed band ligation the commissioning criteria apply. One criteria must be met: Grade I or II haemorrhoids with severe symptoms which include bleeding, faecal soiling, itching or pain which have failed to respond to conservative management for 6 months. Grade III or IV haemorrhoids (i.e. prolapsed) Please add any additional information below CLINICIANS MAY USE THIS FORM TO DECLARE THAT THE INDICATED PROCEDURE IS EXCLUDED FROM THE POLICY FOR THE FOLLOWING REASON: Emergency Reasonable suspicion of cancer It is part of reconstruction following treatment for cancer, traumatic injury or the correction of congenital malformation Not carrying out the procedure would have
