This is the text extract for SA0256 – Perhexiline Maleate, browse documents here.

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

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 1

Form SA0256

November 2009

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

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

Perhexiline Maleate

INITIAL APPLICATION Applications only from a cardiologist or general physician. Approvals valid for 2 years. Prerequisites (tick boxes where appropriate)

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Refractory angina Patient is already on maximal anti-anginal therapy

RENEWAL Current approval Number (if known):............................................................... Applications only from a cardiologist or general physician. Approvals valid for 2 years. Prerequisites (tick box where appropriate)

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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