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Exceptional Circumstances Forms
Find Special Authority forms.
- 1 Application form for Community Exceptional Circumstances (5 pages, 142 KB) 03 Jun 2009
- 2 Application form for Hospital Exceptional Circumstances (4 pages, 131 KB) 03 Jun 2009
- 3 Application form for Cancer Exceptional Circumstances (3 pages, 136 KB) 19 May 2008
- Ethambutol 100 mg tablets - application information & form (2 pages, 96 KB) 29 Apr 2005
- Liothyronine 20mcg tablets - application information & form (3 pages, 116 KB) 29 Aug 2008
- Pharmaceutical Cancer Treatments Paediatric Oncology/Haematology Notification Form (1 page, 39 KB) 20 Jun 2008
- Prednisolone sodium phosphate oral liquid - application information & form (3 pages, 109 KB) 30 Apr 2008
- Propylthiouracil - application information & form (3 pages, 127 KB) 16 Apr 2008
Page updated on 01 Nov 2009
Linked documents
1 Application form for Community Exceptional Circumstances (5 pages, 142 KB)
Return completed form to: Application Form for Community Exceptional Circumstances Approval Exceptional Circumstances Panel Co-ordinator PHARMAC PO Box 10-254, Wellington Phone: 04-916-7553 Facsimile: 09-523-6870 Email: ecpanel@pharmac.govt.nz Please refer to information sheet if necessary. Complete ALL relevant details. Please type or…
2 Application form for Hospital Exceptional Circumstances (4 pages, 131 KB)
Return completed form to: Hospital Exceptional Circumstances PHARMAC PO Box 10-254, Wellington Phone: 04-916-7521 Facsimile: 09-523-6870 Email: ecpanel@pharmac.govt.nz Application Form for Hospital Exceptional Circumstances Instructions: Handwrite CLEARLY using a dark pen (electronic form available on request for typewritten applications). •…
Ethambutol 100 mg tablets - application information & form (2 pages, 96 KB)
With the withdrawal of ethambutol 100 mg tablets from the market, an alternative brand will be funded through Exceptional Circumstances...
Liothyronine 20mcg tablets - application information & form (3 pages, 116 KB)
APPLICATION INFORMATION FOR LIOTHYRONINE 20MCG TABLETS With the withdrawal of the GSK’s brand of liothyronine (Tertroxin) 20mcg tablets from the market, an alternative brand will be funded through Exceptional Circumstances. We are aware that Health Support Limited has been importing…
Pharmaceutical Cancer Treatments Paediatric Oncology/Haematology Notification Form (1 page, 39 KB)
Pharmaceutical Cancer Treatments Paediatric Oncology/Haematology Notification Form Return completed form to: Exceptional Circumstances Panel Coordinator Phone: Fax: 04 916 7553 09 523 6870 Patient details Last name First name Date of birth NHI number Prescribing practitioner details Last name First…
Propylthiouracil - application information & form (3 pages, 127 KB)
APPLICATION INFORMATION FOR PROPYLTHIOURACIL With the withdrawal of the Abbott brand of Propylthiouracil from the market, an alternative source of Propylthiouracil is available from Health Support Limited (HSL). As this product is being sourced from Australia, it is only available…
