CircumcisionSubmission 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-nottscountyccgs@nhs.net

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 DetailsName:Date of Birth:NHS No.GP Practice

Clinician DetailsName:Professional Reference Number: (GMC/NMC)Date:

Organisation NUH SFHFT MSK HH

GP / Other:

I Confirm that the patient meets the current clinical guideline / policy for the restricted procedure as detailed in the Restricted Policy 2018

I Confirm that I have explained the prior approval process to the patient ad that the patient has given consent to share their information with the commissioner

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

Commissioned ONLY for medical and NOT cosmetic or religious reasons.

One of the following commissioning criteria must be met:

Lichen sclerosus (chronic inflammation leading to a rigid fibrous foreskin) in males aged 9 years and over

Distal scarring of the preputial orifice (a short course of topical corticosteroids might help with mild scarring)

Painful erections secondary to a tight foreskin

Recurrent infection (balanitis / balanoposthitis)

Redundant prepuce, phimosis (inability to retract the foreskin due to a narrow prepucial ring) sufficient to cause ballooning of the foreskin on micturition; and paraphimosis (inability to pull forward a retracted foreskin)

Traumatic injury e.g. zipper damage.

Congenital urological abnormalities when skin is required for grafting

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 an adverse

effect on physical functional development of a child