How to fill out this application form.


! This form cannot be parked

Please be aware you cannot park/save a partially completed form using this service.
Make sure you have everything that is necessary to complete this form before submitting it. Please be aware that individual files over 5 megabytes in size will not be accepted, nor will files whose combined size exceed 20 megabytes. If you cannot use this service to apply, you will need to print your downloaded PDF application form and send to PHARMAC at the address on the form.
If this is your first time using this form, we suggest you review the fields required first before completing and submitting the form.


This is where you make an application under the Insulin Pump Panel (IPP).

Applications only from a relevant specialist or nurse prescriber within their vocational scope.

Please read the Special Authority criteria for insulin pumps and consumables.

If you choose to download the PDF application, please read how to save and print the IPP form first. You will need to print your downloaded PDF application form and send to PHARMAC at the address on the form.

Note: All compulsory fields (marked with an '*') for the menu tabs will need to be completed.


* Select:

* Application type: (select one or both)


* Prerequisites:
Applicant is part of a multidisciplinary team experienced in the management of type 1 diabetes care; and
Patient/Parent/Guardian has undertaken carbohydrate counting education (either a carbohydrate counting course or direct education from an appropriate health professional); and
Patient has been evaluated by the multidisciplinary team for their suitability for insulin pump therapy.
* Prerequisites:
Applicant is part of a multidisciplinary team experienced in the management of type 1 diabetes care; and
Patient/Parent/Guardian has undertaken carbohydrate counting education (either a carbohydrate counting course or direct education from an appropriate health professional); and
Patient was already on pump treatment prior to 1 September 2012 and had been evaluated by the multidisciplinary team for their suitability for insulin pump therapy at the time of initiating that pump treatment and continues to benefit from pump treatment.
Pump prerequisite:

Medical history

* Baseline HbA1c result:
(mmol/mol OR %)     (dd/mm/yyyy)
(mmol/mol OR %)     (dd/mm/yyyy)
(mmol/mol OR %)     (dd/mm/yyyy)
* Baseline number of severe hypoglycaemic events:    
(severe defined as requiring the assistance of another person)


* Current HbA1c result:
(mmol/mol OR %)     (dd/mm/yyyy)
(mmol/mol OR %)     (dd/mm/yyyy)
(mmol/mol OR %)     (dd/mm/yyyy)
* Current number of severe hypoglycaemic events:    
(severe defined as requiring the assistance of another person)

Indication

* Select one option only:

Permanent neonatal diabetes prerequisites met:

HbA1c prerequisites met:


Recurrent severe hypoglycaemia prerequisites met:


Patient does not meet any of the above criteria.
You will need to attach relevant documents of support for this application.
* Describe the rationale for this application:

* Describe:
Insulin regimen used prior to pump therapy
Any other relevant information which may help the Panel in assessing this application





Patient Details

* NHI No:
* First Name:
* Last Name:
* Address line 1:
Address line 2:
Address line 3:
Suburb:
City:
Postcode: find postcode
* Gender:
* Date of Birth:
* DHB:





Details of Applying Practitioner

* NZMC#:
* Title:
* First Name:
* Last Name:
* Address line 1:
Address line 2:
Address line 3:
Suburb:
City:
Postcode: find postcode
* Phone:
* Fax:
* Email:

GP Details

NZMC#:
Title:
First Name:
Last Name:
Address line 1:
Address line 2:
Address line 3:
Suburb:
City:
Postcode: find postcode
Phone:
Fax:
Email:



Any other practitioner who needs to be informed

NZMC#:
Title:
First Name:
Last Name:
Address line 1:
Address line 2:
Address line 3:
Suburb:
City:
Postcode: find postcode
Phone:
Fax:
Email:





Applicants will need to attach relevant documents of support, particularly if the prerequisite criteria are not met.


  1. Please attach evidence in support of your application (provide the full journal article, not just the reference or hyperlink, conference proceeding or abstract).
  2. Please attach any additional information which may help the Panel in assessing this application, such as relevant clinic letters, supporting references, lab results, hospital admissions record/s, management plan, and any other information which may be relevant. Note that a higher degree of proof will be required for unregistered medications or registered medications for non-registered indications. List in the table below the information which you are attaching to this application:
  3. To add files to your application, click on the "Add file" button. This will display a button you can click on that will bring up a dialog box where you can select a file to submit. You can submit additional files by clicking on the "Add file" button again and repeating the process.

Important! Please be aware that individual files over 5 megabytes in size will not be accepted, nor will files whose combined size exceed 20 megabytes. If you have files that exceed these limits, please fax or post them to us.




! Saving the application:
  1. If you want to save a copy of your application you will need to ensure that your browser allows popups from www.pharmac.govt.nz.
    - Consult with your IT department; or
    - From the browser menu goto: Tools, Pop-up Blocker, Pop-up Blocker Settings, Add www.pharmac.govt.nz
    (the exact menu options will depend on your browser).
  2. When you press the "Submit" button the popup will then be displayed.
  3. Then in the popup go to the browser menu: File, Save Page As (the exact menu options will depend on your browser).
  4. You will then be able to save a copy of your application.




! Please be patient

As you have attached files to this application, it will take longer to submit the data to us. Please be patient while these files are uploaded.