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Special Authority Forms

General Practitioners and specialists can download individual forms for making Special Authority applications from this page.

Alternatively, all forms are available in one indexed document, Special Authority Forms, November 2009 (162 pages, 457 KB).

If you have any queries regarding the processing of Special Authority Applications, please contact Sector Services on 0800 243 666 or by email.

Find Exceptional Circumstances (EC) forms.

Special Authority forms

Sort by Therapeutic Group or Form Title (Chemical Name)

Alimentary Tract and Metabolism

From page 25 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Blood and Blood Forming Organs

From page 39 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Cardiovascular System

From page 48 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Dermatologicals

From page 58 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Genito-Urinary System

From page 69 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Hormone Preparations - Systemic Excluding Contraceptive Hormones

From page 75 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Infections - Agents for Systemic Use

From page 83 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Musculoskeletal System

From page 100 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Nervous System

From page 109 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Oncology Agents and Immunosuppressants

From page 134 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Respiratory System and Allergies

From page 148 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Sensory Organs

From page 155 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Various

From page 160 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Extemporaneously Compounded Preparations and Galenicals

From page 165 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Special Foods

From page 168 of the Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)

Page updated on 01 Nov 2009


Linked documents

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Special Authority Forms, November 2009 (162 pages, 457 KB)
SPECIAL AUTHORITY FORMS November 2009 Contents Panel Approvals… 4 Alimentary Tract and Metabolism … 5 Blood and Blood Forming Organs…. 14 Cardiovascular System ….. 25 Dermatologicals …. 30 Genito-Urinary System… 34 Hormone Preparations - Systemic Excluding Contraceptive Hormones… 37 Infections…

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Pharmaceutical Schedule, November 2009 (224 pages, 1245 KB)
November 2009 Volume 16 Number 2 Editors Kaye Wilson & Scott Brydon email: schedule@pharmac.govt.nz Telephone +64 4 460 4990 Facsimile +64 4 460 4995 Level 9, Cigna House 40 Mercer Street PO Box 10 254 Wellington Freephone Information Line 0800…

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SA0473 - Imiglucerase (Cerezyme) therapy - initial application (6 pages, 72 KB)
Initial application form for imiglucerase (Cerezyme) therapy Send completed applications to: Gaucher Panel Co-ordinator PHARMAC P O Box 10-254 WELLINGTON Fax: (04) 460 4995 Phone: (04) 460 4990 Email: gaucherpanel@pharmac.govt.nz Date of Application: _________________________________________ Patient Name: NHI number: Date of…

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SA0473 - Imiglucerase (Cerezyme) therapy - renewal application (3 pages, 75 KB)
Renewal application for imiglucerase (Cerezyme) therapy Send completed applications to: Gaucher Panel Co-ordinator PHARMAC P O Box 10-254 WELLINGTON Fax: (04) 460 4995 Phone: (04) 460 4990 Email: gaucherpanel@pharmac.govt.nz Date of Application: _________________________________________ Patient Name: NHI number: _________________________________________ Date of…

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SA0855 – Multiple Sclerosis treatments, Initial Application for beta-interferon or glatiramer acetate (8 pages, 183 KB)
INITIAL APPLICATION FOR FUNDING OF BETA-INTERFERON OR GLATIRAMER ACETATE Please send applications to: The Co-ordinator MSTAC PHARMAC P O Box 10-254 WELLINGTON Phone: 04 460 4990 Facsimile: 04 916 7571 Email: mstaccoordinator@pharmac.govt.nz Applications must be complete and accompanied by all…

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SA0855 – Multiple Sclerosis treatments, Renewal Application form for beta-interferon or glatiramer acetate (5 pages, 171 KB)
RENEWAL APPLICATION FOR FUNDING OF BETA-INTERFERON OR GLATIRAMER ACETATE For patients who are currently being treated with beta-interferon or glatiramer acetate (with New Zealand government funding) Please send applications to: The Co-ordinator MSTAC PHARMAC P O Box 10-254 WELLINGTON Phone:…

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