This is the text extract for SA0963 – MultivitaminsPaediatric Seravit: Ketovite, Ketovite, Paediatric Seravit, browse documents here.

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

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 1

Form SA0963

August 2010

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

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

Multivitamins (Ketovite; Ketovite; Paediatric Seravit)

INITIAL APPLICATION Applications from any relevant practitioner. Approvals valid without further renewal unless notified. Prerequisites (tick boxes where appropriate)

or

u u

The patient has inborn errors of metabolism For use as a supplement to a ketogenic diet in patients diagnosed with epilepsy

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

u

Patient has had a previous approval for multivitamins

Note: Use of Paediatric Seravit is not recommended as a supplement to a ketogenic diet.

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