This is the text extract for SA0467 – Alendronate for Paget’s Disease: Alendronate Tab 40 mg, browse documents here.

Ministry of Health Phone 0800 243 666 APPLICANT (stamp or sticker acceptable)

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 1

Form SA0467

February 2009

PATIENT NHI: ...................................................... REFERRER Reg No: ............................................

Reg No: ................................................................ First Names: ......................................................... First Names: ......................................................... Name: ................................................................... Surname: .............................................................. Surname: .............................................................. Address: ............................................................... DOB: ..................................................................... Address: ............................................................... ............................................................................... Address: ............................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... Fax Number: ......................................................... ............................................................................... Fax Number: .........................................................

Alendronate for Paget’s Disease (Alendronate Tab 40 mg)

INITIAL APPLICATION Applications only from a relevant specialist. Approvals valid for 6 months. Prerequisites (tick boxes where appropriate)

and

u u u u u u

or or or or

Paget’s disease

Bone or articular pain Bone deformity Bone, articular or neurological complications Asymptomatic disease, but risk of complications due to site (base of skull, spine, long bones of lower limbs) Preparation for orthopaedic surgery

RENEWAL Current approval Number (if known):............................................................... Applications only from a relevant specialist. Approvals valid for 6 months. Prerequisites (tick box where appropriate)

u

The treatment remains appropriate and the patient is benefiting from treatment

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

Post application to Ministry of Health, Private Bag 3015, Wanganui – Fax: 0800 100 131