This is the text extract for SA0943 – Letrozole, browse documents here.

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Ministry of Health Phone 0800 243 666

APPLICATION FOR ALTERNATE SUBSIDY BY SPECIAL AUTHORITY

Page 1

Form SA0943

November 2009

APPLICANT (stamp or sticker acceptable)

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

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

Letrozole

INITIAL APPLICATION - New patients Applications only from a relevant specialist. Approvals valid for 5 years. Prerequisites (tick boxes where appropriate)

and and

u u u u

or

Patient is a postmenopausal woman Patient has hormone receptor positive early breast cancer

The patient has a very clear history of intolerance to tamoxifen The use of tamoxifen is contraindicated due to a history of thromboembolic disease

INITIAL APPLICATION - Patient has had a Special Authority approval for letrozole prior to 1 December 2008 Applications only from a relevant specialist. Approvals valid without further renewal unless notified. Prerequisites (tick box where appropriate)

u

The treatment remains appropriate and the patient is benefiting from treatment

RENEWAL Current approval Number (if known):............................................................... Applications only from a relevant specialist. Approvals valid without further renewal unless notified. Prerequisites (tick box where appropriate)

u

The treatment remains appropriate and the patient is benefiting from treatment

Note: If the patient had an approval for letrozole prior to 1 December 2008 the applicant is required to submit a fresh initial application in the first instance, not a renewal application. Please phone Ministry of Health Sector Services on 0800 243 666 for clarification if needed.

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