Abacavir Sulphate with Lamivudine and Zidovudine
Highly Specialised Drugs Program Declaration Form*
| Patient’s Name: | ____________________________________ |
| Medical Record Number: | ____________________________________ |
| Medicare Number: | ____________________________________ |
I certify that the above patient meets the Pharmaceutical Benefits Advisory Committee’s criteria for funding under Section 100 of the National Health Act, 1953.
Criteria
Initial treatment of HIV infection in a patient over 12 years of age, weighing 40kg or more, with a CD4 cell count of less than 500 per cubic millimetre or symptomatic HIV disease.
Continuing treatment of HIV infection where the patient over 12 years of age, weighing 40kg or more, has previously received PBS-subsidised therapy for HIV infection.
Specialist /Authorised Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
Additional information to be provided by authorised general practitioners only:
| Provider Number: | ____________________________________ |
| Practice Address: | ____________________________________ |
| Telephone Number: | ____________________________________ |
*To be completed by the specialist or authorised prescriber initiating drug treatment, and retained by the hospital Pharmacy Department.
March 2012