Funding For Treatment In The European Economic Area (Eea) Application Form Page 9
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10Part 7: Declaration by the Patient
I declare that all the information provided is correct and complete. I understand and accept that if
I knowingly withhold information or provide false or misleading information, I may be liable to
prosecution and/or civil proceedings.
I consent to the disclosure of all information relating to my application to and by NHS England,
the Department of Health, the Department for Work and Pensions (DWP), NHS Protect and
other NHS organisations / external parties, necessary for the processing and verification of this
claim and the investigation, prevention, detection and prosecution of fraud.
I understand that the NHS is not liable for the care received abroad when funded via the S2 or
Directive route.
If applying for reimbursement of costs, I hereby confirm that I have received the treatment(s)
described and understand that the person who received and paid for treatment(s), will normally
receive any reimbursement due.
I hereby give permission for the person identified as the Applicant in Part 9 of this form to make
this application on my behalf (if applicable).
Name of patient
Signature of patient
Date
Part 8: Confirmation of the Applicant
Are you (the patient) also the applicant?
Yes
No – Please complete Parts 9 & 10
Part 9: Declaration by the Applicant
I declare that I am applying with the consent of the patient / I am legally empowered to act on
behalf of the patient (delete as appropriate)
Name of applicant
Signature of applicant
Date
Part 10: Details of the Applicant
Family name
First name(s)
Relationship to patient
Title
Telephone number
Email
Applicant’s address
(for correspondence)
Please note, even if you are acting on behalf of the patient, proof of the patient’s residence, as
per the guidance notes, must still be submitted. Parents applying on behalf of their children are
required to submit evidence of their own residence for the permanent address given.
9a. EEA application form (10 /14)
Page 9 of 10
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