This is the text extract for SA0880 – Docetaxel, 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 SA0880

June 2011

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

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

Docetaxel

INITIAL APPLICATION 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 u

or

The patient has ovarian*, fallopian* or primary peritoneal cancer*

Has not received prior chemotherapy Has received prior chemotherapy but has not previously been treated with taxanes

or or

u u u

and and

The patient has metastatic breast cancer

The patient has early breast cancer Docetaxel is to be given concurrently with trastuzumab

or

u u u

or

The patient has non small-cell lung cancer

Has advanced disease (stage IIIa or above) Is receiving combined chemotherapy and radiotherapy

or

and

u u

The patient has small-cell lung cancer* Docetaxel is to be used as second-line therapy

RENEWAL 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 12 months. Prerequisites (tick boxes where appropriate)

and

u u u

or

The patient has metastatic breast cancer, non small-cell lung cancer, or small-cell lung cancer*

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

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 SA0880

June 2011

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

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

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