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Post/fax applications to: Health Benefits Private Bag 3015, Wanganui

Enquiries: Phone: (06) 345 3549 Fax: 0800 100 131

SPECIAL AUTHORITY APPLICATION FORM FOR

methylphenidate & dexamphetamine

Before completing this form, you should consult the Special Authority Criteria in the Pharmaceutical Schedule and the diagnostic criteria on the following page (please use block capitals or a typewriter). PRESCRIBER DETAILS (stamp or sticker acceptable)

Name: ......................................................................................... Address: ..................................................................................... ..................................................................................................... ..................................................................................................... Fax Number: .............................................................................. Registration No: ......................................................................... Speciality: Child & Adolescent Psychiatrist Adult Psychiatrist Paediatrician Respiratory Physician Neurologist General Practitioner (GP) If you are a GP making this application please indicate the Specialist on whose advice you are initiating/continuing treatment. Specialist’s name: ……………………………………….. Town: …………………………………………………... Speciality Child & Adolescent Psychiatrist Paediatrician D.O.B:

PATIENT DETAILS

First Names: ......................................................................... Surname: .............................................................................. Address: ............................................................................... ............................................................................. ............................................................................. ………./………../………

NHI No: ……………. Initial application Renewal

Note: Applications for ADHD patients under 5 years of age must be made by either a Child & Adolescent Psychiatrist or a Paediatrician Applications for Narcoleptic patients must be made by a Neurologist or Respiratory Physician.

Adult Psychiatrist

DIAGNOSIS (tick one)

Narcolepsy Attention Deficit and Hyperactivity Disorder (ADHD) - Diagnosis according to DSM-IV/ICD 10 criteria (refer to reverse of this form) Methylphenidate 10 mg tablets and/or 20 mg slow release tablets Dexamphetamine 5 mg tablets

TREATMENT

Stimulant • • • • •

OTHER NOTES AND INFORMATION

DSM-IV criteria are provided on reverse of this form for your reference. Special Authority numbers must be annotated on each prescription for subsidy purposes. Annotation of any “specialist recommendation” on the prescription form is therefore not required. For ADHD patients under 5 years of age the initial prescription should be written by a Child & Adolescent Psychiatrist or a Paediatrician. For narcoleptic patients the initial prescription should be written by a Neurologist or Respiratory Physician. Approvals for ADHD patients under 5 years of age are valid for 12 months. All other approvals are valid for 24 months.

I confirm the above details are correct and that in signing this form I understand I may be audited. Signed: ………………………………………………………………….. Date: …………………………

Failure to complete the form correctly will result in a delay in approval and the return of your application. #55542 February 2001, source: www.PHARMAC.govt.nz


DSM-IV Diagnostic Criteria for ADHD (1996)

A: Either 1 or 2

1. Six or more of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level: a. b. c. d. e. f. g. h. i. 2 Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities. Often has difficulty sustaining attention in tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, or chores or duties in the workplace (not due to oppositional behaviour or failure to understand instructions). Often has difficulty organising tasks and activities Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as homework). Often loses things necessary for tasks or activities (toys, school assignments, pencils, books or tools). Is often distracted by extraneous stimuli. Is often forgetful in daily activities.

Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental levels.

Hyperactivity

a. b. c. d. e. f.

Often fidgets with hands or feet or squirms in seat. Often leaves seat in classroom or in other situations in which remaining seated is expected. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness). Often has difficulty playing or engaging in leisure activities quietly. Is often “on the go” or often acts as if “driven by motor”. Often talks excessively.

Impulsivity

g. h. i.

Often blurts out answers before questions have been completed. Often has difficulty awaiting turn. Often interrupts or intrudes on others (such as butting into conversations or games).

B: Some hyperactive, impulsive or inattentive symptoms that caused impairment were present before age 7 years . C: Some impairment from the symptoms is present in two or more settings (such as in schoolwork and at home). D: There must be clear evidence of clinically significant impairment in social, academic or occupational functioning. E: The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or

another psychotic disorder and are not better accounted for by another mental disorder (such as mood, anxiety, dissociative or personality disorder).

ADHD types using DSM-IV criteria

ADHD, predominantly inattentive type: meets inattention criteria (section A1) for the past 6 months. ADHD, predominantly hyperactive-impulsive type: meets hyperactive-impulsive criteria (section A2 for the past 6 months) ADHD, combined type: meets criteria for section A1 and section A2 for the past 6 months.

ENQUIRIES REGARDING SPECIAL AUTHORITY APPLICATIONS TELEPHONE: 06 345 3549

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Methylphenidate and dexamphetamine

Abstract

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