Pills

This is the text extract for SA0702 – Adult Products Standard: Ensure Plus, Fibresource, Fortisip, Isosource, Jevity, Nutrison, Osmolite, Resource Plus, browse documents here.


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

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 1

Form SA0702

March 2011

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

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

Adult Products Standard (Ensure Plus; Fibresource; Fortisip; Isosource; Jevity; Nutrison; Osmolite; Resource Plus)

INITIAL APPLICATION - Oral feed for cystic fibrosis patient Applications only from a relevant specialist. Approvals valid for 3 years. Prerequisites (tick boxes where appropriate)

and

u u u

or

Cystic fibrosis

The product is to be used as a supplement The product is to be used as a complete diet

INITIAL APPLICATION - Oral feed for indications other than cystic fibrosis Applications only from a relevant specialist. Approvals valid for 1 year. Prerequisites (tick boxes where appropriate)

or or

u u u u u

any condition causing malabsorption failure to thrive increased nutritional requirements

and The product is to be used as a supplement The product is to be used as a complete diet

or

RENEWAL - Oral feed cystic fibrosis patient Current approval Number (if known):............................................................... Applications only from a relevant specialist or general practitioner on the recommendation of a relevant specialist. Approvals valid for 3 years. 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

The product is to be used as a supplement The product is to be used as a complete diet

and General Practitioners must include the name of the specialist and date contacted: .........................................................................................................

Use next page for: Initial application - Enteral feed and Renewal - Enteral feed or Oral feed for indications other than cystic fibrosis 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


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

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 2

Form SA0702

March 2011

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

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

Adult Products Standard (Ensure Plus; Fibresource; Fortisip; Isosource; Jevity; Nutrison; Osmolite; Resource Plus) - continued

INITIAL APPLICATION - Enteral feed Applications only from a relevant specialist. Approvals valid for 1 year. Prerequisites (tick boxes where appropriate)

or or or or

u u u u u u u

enteral feeding nasogastric nasoduodenal nasojejunal gastrostomy/jejunostomy

and The product is to be used as a supplement The product is to be used as a complete diet

or

RENEWAL - Enteral feed or Oral feed for indications other than cystic fibrosis Current approval Number (if known):............................................................... Applications only from a relevant specialist or general practitioner on the recommendation of a relevant specialist. Approvals valid for 1 year. 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

The product is to be used as a supplement The product is to be used as a complete diet

and General Practitioners must include the name of the specialist and date contacted: ......................................................................................................... Note: This group of products can be used either as a supplement or as a complete diet. If a product is being used as a supplement, the limit is 500 ml per day. Cystic fibrosis patients are exempt the 500 ml per day volume restriction when using Ensure Plus, Fortisip or Resource Plus as a supplement.

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

Metadata

Title

SA0702 – Adult Products Standard: Ensure Plus, Fibresource, Fortisip, Isosource, Jevity, Nutrison, Osmolite, Resource Plus

Abstract

Special Authority for Subsidy

Page 1

icon

Note

This text has been extracted from the source PDF document.

Also available as plain text.

Please contact webmaster to discuss alternative format options.