This is the text extract for SA0961 – Rituximab, browse documents here.

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

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 1

Form SA0961

September 2010

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

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

Rituximab

INITIAL APPLICATION - Post-transplant Applications only from a relevant specialist or any other medical practitioner on the recommendation of a relevant specialist. Approvals valid for 12 months. Prerequisites (tick boxes where appropriate)

and

u u

The patient has B-cell post-transplant lymphoproliferative disorder* To be used for a maximum of 8 treatment cycles

INITIAL APPLICATION - Indolent, Low-grade lymphomas Applications only from a relevant specialist or any other medical practitioner on the recommendation of a relevant specialist. Approvals valid for 9 months. Prerequisites (tick boxes where appropriate)

and

u u u u

The patient has indolent low grade NHL with relapsed disease following prior chemotherapy To be used for a maximum of 4 treatment cycles

or The patient has indolent, low grade lymphoma requiring first-line systemic chemotherapy To be used for a maximum of 6 treatment cycles

and

Note: 'Indolent, low-grade lymphomas' includes follicular, mantle, marginal zone and lymphoplasmacytic/Waldenstrom macroglobulinaemia. Rituximab is not funded for Chronic lymphocytic leukaemia/small lymphocytic lymphoma.

INITIAL APPLICATION - Aggressive CD20 positive NHL Applications only from a relevant specialist or any other medical practitioner on the recommendation of a relevant specialist. Approvals valid for 12 months. Prerequisites (tick boxes where appropriate)

and and

u u u

The patient has treatment-naive aggressive CD20 positive NHL To be used with a multi-agent chemotherapy regimen given with curative intent To be used for a maximum of 8 treatment cycles

Note: 'Aggressive CD20 positive NHL' includes large B-cell lymphoma and Burkitt's lymphoma/leukaemia

Use next page for: Renewal - Indolent, Low-grade lymphomas and Renewal - Post-transplant 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

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

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 2

Form SA0961

September 2010

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

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

Rituximab - continued

RENEWAL - Indolent, Low-grade lymphomas Current approval Number (if known):............................................................... Applications only from a relevant specialist or any other medical practitioner on the recommendation of a relevant specialist. Approvals valid for 9 months. Prerequisites (tick boxes where appropriate)

and and

u u u

The patient has had a rituximab treatment-free interval of 12 months or more The patient has indolent, low-grade NHL with relapsed disease following prior chemotherapy To be used for no more than 4 treatment cycles

Note: 'Indolent, low-grade lymphomas' includes follicular, mantle, marginal zone and lymphoplasmacytic/Waldenstrom macroglobulinaemia. Rituximab is not funded for Chronic lymphocytic leukaemia/small lymphocytic lymphoma.

RENEWAL - Post-transplant Current approval Number (if known):............................................................... Applications only from a relevant specialist or any other medical practitioner on the recommendation of a relevant specialist. Approvals valid for 9 months. Prerequisites (tick boxes where appropriate)

and and

u u u

The patient has had a rituximab treatment-free interval of 12 months or more The patient has B-cell post-transplant lymphoproliferative disorder* To be used for no more than 6 treatment cycles

Note: Indications marked with * are Unapproved Indications.

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