Complex surgery fee uplift request form This form is designed to provide us with the information we need to assess eligibility for a surgical fee uplift. Please complete all sections of the form and ensure that it is signed by a Bupa recognised consultant. We would appreciate it if the information you provide is typed and not handwritten. We are unable to assess forms that are incomplete or do not have a valid signature. If we receive a form that is incomplete, we will contact the named consultant to ask them to resubmit the form with all the required information. We use evidence-based best practice guidelines when making decisions about treatment eligibility for funding in line with members’ policies and hospital agreements. Please ensure that all sections are completed in full and you supply all necessary supporting information, as we are unable to contact other providers to obtain the information. We are unable to assess incomplete forms and this will delay our answer. If you have any questions please contact us on 0345 755 3333. Lines are open 8am to 6pm Monday to Friday. We may record or monitor our calls. Please return the completed form to us either by secure fax on: 01784 234 290 Or, if you would like to send the form by email please set up a secure route by emailing [email protected]. Please do not use unsecure email to send patient-identifable data. Section 1 About the patient Miss First name Mrs Ms Mr Dr other (please state) Last name Date of birth Address D D M M Y Y Y Y Postcode Bupa membership number Section 2 About the consultant and hospital Name of requesting consultant Specialty Hospital name Please confrm that you have explained to the patient about your fees and charges in writing in advance of their procedure (where possible) 2 : No I have not let the Bupa patient know about my fees/charges in writing my fees/charges No, it is not possible to let the Bupa patient know about my fees/charges (please explain why below) Yes, I have let the Bupa patient know about 2 GMC Good Medical Practice: Financial & commercial dealings www.gmcuk.org/guidance/good_medical_practice/probity_fnancial_and_commercial_dealings.asp BMA Good Billing Practice: A Guide for Private Practitioners, BMA 2009