This is the text extract for SA0907 – Dexamphetamine Sulphate, 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 SA0907

December 2010

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

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

Dexamphetamine Sulphate

INITIAL APPLICATION - ADHD in patients 5 or over – new patients Applications only from a paediatrician, psychiatrist or any other medical practitioner on the recommendation of a relevant specialist. Approvals valid for 24 months. Prerequisites (tick boxes, and write the data requested in the space provided where appropriate)

and and

u u u u

or

ADHD (Attention Deficit and Hyperactivity Disorder) patients aged 5 years or over Diagnosed according to DSM-IV or ICD 10 criteria

Applicant is a paediatrician or psychiatrist Applicant is a medical practitioner and confirms that a relevant specialist has been consulted within the last 2 years and has recommended treatment for the patient

and Provide name of the recommending specialist: .......................................................................................................................................

INITIAL APPLICATION - ADHD in patients 5 or over - patient has had an approval for dexamphetamine for ADHD prior to 1 April 2008 Applications only from a paediatrician, psychiatrist or any other medical practitioner on the recommendation of a relevant specialist. Approvals valid for 24 months. Prerequisites (tick boxes, and write the data requested in the space provided where appropriate)

and

u u u

or

The treatment remains appropriate and the patient is benefiting from treatment

Applicant is a paediatrician or psychiatrist Applicant is a medical practitioner and confirms that a relevant specialist has been consulted within the last 2 years and has recommended treatment for the patient

and Provide name of the recommending specialist: .......................................................................................................................................

INITIAL APPLICATION - ADHD in patients under 5 – new patients Applications only from a paediatrician or psychiatrist. Approvals valid for 12 months. Prerequisites (tick boxes where appropriate)

and

u u

ADHD (Attention Deficit and Hyperactivity Disorder) patients under 5 years of age Diagnosed according to DSM-IV or ICD 10 criteria

Use next page for: Initial application - ADHD in patients under 5 - patient has had an approval for dexamphetamine for ADHD in patients under 5 prior to 1 April 2008, Initial application - Narcolepsy – new patients, Initial application - Narcolepsy - patient has had an approval for dexamphetamine for narcolepsy prior to 1 April 2008, Renewal - ADHD in patients 5 or over, Renewal - ADHD in patients under 5 and Renewal - Narcolepsy 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 SA0907

December 2010

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

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

Dexamphetamine Sulphate - continued

INITIAL APPLICATION - ADHD in patients under 5 - patient has had an approval for dexamphetamine for ADHD in patients under 5 prior to 1 April 2008 Applications only from a paediatrician or psychiatrist. Approvals valid for 12 months. Prerequisites (tick box where appropriate)

u

The treatment remains appropriate and the patient is benefiting from treatment

INITIAL APPLICATION - Narcolepsy – new patients Applications only from a neurologist or respiratory specialist. Approvals valid for 24 months. Prerequisites (tick box where appropriate)

u

The patient suffers from narcolepsy

INITIAL APPLICATION - Narcolepsy - patient has had an approval for dexamphetamine for narcolepsy prior to 1 April 2008 Applications only from a neurologist or respiratory specialist. Approvals valid for 24 months. Prerequisites (tick box where appropriate)

u

The treatment remains appropriate and the patient is benefiting from treatment.

Use next page for: Renewal - ADHD in patients 5 or over, Renewal - ADHD in patients under 5 and Renewal - Narcolepsy 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 3

Form SA0907

December 2010

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

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

Dexamphetamine Sulphate - continued

RENEWAL - ADHD in patients 5 or over Current approval Number (if known):............................................................... Applications only from a paediatrician, psychiatrist or any other medical practitioner on the recommendation of a relevant specialist. Approvals valid for 24 months. Prerequisites (tick boxes, and write the data requested in the space provided where appropriate)

and

u u u

or

The treatment remains appropriate and the patient is benefiting from treatment

Applicant is a paediatrician or psychiatrist Applicant is a medical practitioner and confirms that a relevant specialist has been consulted within the last 2 years and has recommended treatment for the patient

and Provide name of the recommending specialist: ....................................................................................................................................... Note: If the patient had an approval for dexamphetamine for ADHD prior to 1 April 2008 the applicant is required to submit a fresh initial application in the first instance, not a renewal application. Please phone the Contact Centre on 0800 243 666 for clarification if needed.

RENEWAL - ADHD in patients under 5 Current approval Number (if known):............................................................... Applications only from a paediatrician or psychiatrist. Approvals valid for 12 months. 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 dexamphetamine for ADHD in patients under 5 prior to 1 April 2008 the applicant is required to submit a fresh initial application in the first instance, not a renewal application. Please phone the Contact Centre on 0800 243 666 for clarification if needed.

RENEWAL - Narcolepsy Current approval Number (if known):............................................................... Applications only from a neurologist or respiratory specialist. Approvals valid for 24 months. 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 dexamphetamine for narcolepsy prior to 1 April 2008 the applicant is required to submit a fresh initial application in the first instance, not a renewal application. Please phone the Contact Centre 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