HCA UK Patient Referral Form

This is the digital version of your referrals form as set out in Schedule 1 of your contract.


The submission by the Advisor of a Referral Form is not intended and shall not constitute a binding agreement between the parties nor shall it fetter in any way HCA’s absolute discretion to determine to whom it shall provide Healthcare Services.


The submission of this Referral Form is also confirmation that the Advisor has obtained all necessary consents for the sharing of personal data with HCA by the proposed patient and that data is being processed in accordance with the UK General Data Protection Regulation and the Data Protection Act 2018.


For the avoidance of doubt, only referrals submitted prior to admission date will be eligible for the Advisor Service Fee.


If you have any questions please contact your international business relations manager or send an email to internationalreferrals@hcahealthcare.co.uk

Referral advisor details

About the patient

Home address

London Address (if known)

How will the account be settled?

Payment type, required field

About the treatment sought

Information provided by

I certify that the information on this form has been checked with the patient or patient’s representative. I have explained to the patient / patient’s representative that the purpose of recording and transmitting this information is:
a) to support HCA UK‘s consideration of the application for HCA healthcare UK services
b) if the application is approved, to provide those healthcare services (this may include scheduling appointments with the relevant hospital and arranging travel, visas and accommodation)
c) to release medical record information about the patient for the purposes of facilitating treatment.
The patient / patient’s representative has been made aware by you that they may withdraw consent at any time by contacting International Business.

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