This is the text extract for SA0869 – Capecitabine, browse documents here.

---

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

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 1

Form SA0869

August 2010

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

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

Capecitabine

INITIAL APPLICATION Applications only from a relevant specialist. Approvals valid for 12 months. Prerequisites (tick boxes where appropriate)

or or or

u u u u u

and

The patient has advanced gastrointestinal malignancy The patient has metastatic breast cancer* The patient has stage III (Duke's stage C) colorectal*# cancer and undergone surgery

The patient has poor venous access or needle phobia* The patient requires a substitute for single agent fluoropyrimidine*

RENEWAL Current approval Number (if known):............................................................... Applications only from a relevant specialist. Approvals valid for 12 months. Prerequisites (tick boxes where appropriate)

or

u u

The patient requires continued therapy The tumour has relapsed and requires re-treatment

Note: Indications marked with * are Unapproved Indications, # capecitabine is approved for stage III (Duke's stage C) colon cancer.

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