Microsuction for Ear Wax and Debris Removal Application Form

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Description: Please complete this form if your patient meets the criteria outlined in Sections 3. and 4. of the Policy

If your patient falls within the Criteria Based Access element of the policy and the patient demonstrably meets the specific criteria for treatment, the patient can be referred directly via the appropriate Referral Service with a standard referral letter.

If your patient falls within the Prior Approval criteria of the policy (sections 3 and 4) prior approval must be obtained from the EFR Team before secondary care referral is made.