Mycophenolate Sodium

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					HIGHLY SPECIALISED DRUG PROGRAM

ELIGIBILITY STATEMENT
___________________________________________________________________________ HOSPITAL: ................................................................................................................................ PATIENT’S NAME OR CODE: .............................................................................................. MEDICAL RECORD NUMBER: ............................................................................................ MEDICARE NUMBER: ...........................................................................................................
If the patient’s Medicare number has not been recorded above, I certify that the patient is an eligible person and evidence of this is available in the patient’s record. (Eligible person means Australian resident, a person covered by a Reciprocal Health Care Agreement, or an ‘eligible overseas representative’). Signature of prescriber: ..............................................................................................................................................

DRUG:

MYCOPHENOLATE SODIUM
(180 mg and 360 mg tablets of mycophenolic acid)

I confirm that the above patient

complies

does not comply

with the definition of an eligible patient under the National Health Act, and with the following criteria for funding under Section 100 of the Pharmaceutical Benefits Scheme. I agree to make the relevant records available for audit if required. CAUTION: Careful monitoring of patients is mandatory.

ELIGIBLE INDICATIONS FOR HSD PROGRAM
(please tick appropriate box)

Management of rejection, under the supervision and direction of a transplant unit, in patients receiving this drug for: Prophylaxis of renal allograft rejection. Management includes initiation, stabilisation and review of therapy as required.
NAME OF PRESCRIBER: ................................................................................................................................. (please print) SIGNATURE OF PRESCRIBER: ............................................................................................. DATE: ..................................

___________________________________________________________________________
[For office use] CERTIFICATION OF AUDIT: I certify than an audit of this patient’s chart confirms compliance with approved HSD indications Signed: ............................................................................................................................................................ Date: .................................

(This form should be completed by the prescriber and retained by the Pharmacy Department in order to attract funding under the HSD program. A photocopy of this form including pharmacy endorsement certifying chart compliance with approved indications should be made available to a patient returning to another hospital for supplies of drugs).
(S100MycophenolateSodium.doc/S100pdfs/mn)