This is the text extract for 2 Application form for Hospital Exceptional Circumstances, browse documents here.

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Return completed form to:

Hospital Exceptional Circumstances PHARMAC PO Box 10-254, Wellington Phone: 04-916-7521 Facsimile: 09-523-6870 Email: ecpanel@pharmac.govt.nz

Application Form for Hospital Exceptional Circumstances

Instructions:

Handwrite CLEARLY using a dark pen (electronic form available on request for typewritten applications). • Supply all relevant information, attach any additional information. • Include relevant references and clinical reports to support the proposed course of treatment. • Please print off the form and fax it in to avoid transmitting patient information via email.

Eligibility for Hospital EC

Does the following apply? You are a vocationally-registered specialist employed in a public hospital; Applying for approval to fund from a hospital budget; An unsubsidised pharmaceutical for use in the community

Yes to all

Eligible to apply for HEC

No for any

Not eligible to apply for HEC

Sole criterion for Hospital Exceptional Circumstances

Demonstration that funding this pharmaceutical by the hospital for this patient for use in the community would be more cost-saving for the hospital than the reasonable alternative treatment options

Patient Details NHI: Gender: Date of Birth: Surname: First Name/s: Address: Phone: Fax (All responses are faxed): Email: DHB: The Disease/Condition

What is the disease/condition that is to be treated?

Details of Applying Practitioner Last Name: First Name: Dept: Hospital: NZMC#:

Specialty: The Pharmaceutical

What is the unsubsidised pharmaceutical that is being requested for the hospital to fund to use in the community?

Chemical Name: Brand Name: Manufacturer: Form and Strength: Dosage to be used: Dosage regimen (where applicable): Duration of treatment (maximum duration is 12 months):

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1. RAtionAlE FoR HospitAl ExCEptionAl CiRCumstAnCEs

1. Rationale for course of treatment:

(Please continue on page 4 if there is more information than the space provided here.)

2. AltERnAtivE tREAtmEnt options

Please provide details of the subsidised pharmaceuticals which have been trialled already, or have been considered unsuitable

Pharmaceutical Trialled (Y/N) Unsuitable due to

(Please continue on page 4 if there is more information than the space provided here.)

3. HospitAl Admission HistoRy

Please provide the relevant hospital admission history for this patient, and/or attach the discharge summary.

Date Admitted Date Discharged Reason for Admission

(Please continue on page 4 if there is more information than the space provided here.)

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4. dHB dEtAils

A: Which DHB is treating the patient? B: In which DHB does the patient reside? C: Which DHB has agreed to fund this treatment? D: Has the DHB agreed in writing to fund the treatment if it is approved under HEC? (Please gain agreement before applying for HEC). E: Which hospital pharmacy would dispense this if it is approved? (Please ensure hospital pharmacy is aware of your application)

5. spECiFiC Costings

Completing the following table in addition to providing a written rationale will assist the Panel to assess this application. (Costings information may be completed by your Hospital Manager. However, the hospital specialist applicant must quantify the clinical risks and benefits

B. Costs to the hospital of the likely alternative/s

A. Costs to the hospital of using HEC Drug related costs Cost of the treatment for its duration or 1 year Other Costs These may include other financial and/ or non-financial costs associated with the treatment for its duration or 1 year. The Panel will assume a cost per day of $500 for in-hospital care unless information is provided outlining greater costs. Clinical Risks and Benefits What is the likelihood (estimate) that the patient will benefit (describe) with this treatment over the alternative? What is the likelihood (estimate) that the patient will suffer adverse events, hospitalisations or decreased health status if this treatment not provided in the community? Total Cost to Hospital

A $

B $

Net financial impact on hospital of using HEC (A – B)

$

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6. AttACHmEnts

Please attach any additional information which may help the Panel in assessing this application, such as relevant clinic letters, supporting references, lab results, hospital admission records, management plan, and any other information which may be relevant. Please list in the table below the information which you are attaching to this application:

Additional information which is attached to this application (to be completed by applicant):

1. 2. 3. 4. 5.

(Please continue on page 4 if there is more information than the space provided here.)

7. AdditionAl inFoRmAtion

Signature of Applicant:

Date: