Funding For Treatment In The European Economic Area (Eea) Application Form Page 2
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10Part 1: Application Route
Treatment
On what basis is the treatment being provided?
Private system
or
State system
Before or
I am applying before receiving treatment in another EEA country
after
I am applying after receiving treatment in another EEA country
treatment
Application
S2: I want to apply for funding via the S2 route (before treatment only in
route
the state system)
(please tick one
Directive - pre: I want to apply before treatment, for funding for
box only.
treatment not classed as ‘specialised’ (state or private)
Complete a
Directive - post: I want to apply after treatment, for funding for
separate
treatment not classed as ‘specialised’ (state or private)
application form
Directive - Specialised: I want to apply before treatment, for funding for
for each
category)
a specialised treatment subject to prior authorisation (state or private)
Medical Delay Are you seeking treatment abroad because of a medical delay in being
treated by the NHS?
Yes
No
If Yes, please provide evidence that this delay was deemed to be “medically
unacceptable” and assessed as such by a UK NHS clinician.
Part 2: Patient Details
Family name
First name(s)
Date of Birth
Sex
Telephone number
Email
Address
This is normally a
3-3-4
NHS number
digit format
National Insurance No.
Permanent address in England (inc. postcode)
Alternative address for correspondence (if applicable)
GP Name / Registered GP practice (this must be the GP you were registered with at the time
of the treatment you are applying for):
GP address (inc. postcode)
9a. EEA application form (10 /14)
Page 2 of 10
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