This form is not for authorisation of treatment. Authorisation should be undertaken in the usual way with your patient contacting Customer Service.

All requests must be submitted at least 5 working days before surgery takes place, in line with our billing principles.

If surgery is within 5 working days, your request will need to be submitted post-operatively here.

For multiple specialist requests we need:

• Each specialist's details
• Explanation of why each specialist needs to be in surgery
• Anticipated procedure length and an indication of time in theatre for each specialist
• Explanation of what each specialist will do
• Indication of fees for each specialist
• Any supporting clinical guidance.

For pre-operative uplift requests we will provide an estimated fee. To do this we need:

• Explanation of why an enhanced fee is appropriate
• The estimated time in theatre
• Indication of what you are likely to charge based on this
• Full descriptions of the procedure being performed and any procedure codes.

Important: Uploaded documents must be clearly legible, or we won't be able to review your request. To keep our systems secure we can't accept documents with full stops in the file name itself. (So a file named Smith.05.05.doc, for example, needs to be renamed Smith-05-05.doc)

If you need to upload more than one document, please upload your files here